Coroner: Hospital death an accident
IPSWICH Hospital today has lessons to learn after mistakes were made when a patient fell over on a ward and died, an inquest heard.The inquest into the death of Audrey Keyland, of Broomhayes, Ipswich, heard that she died from pressure on her brain as a result of a blood clot a day after she had a fall.
IPSWICH Hospital today has lessons to learn after mistakes were made when a patient fell over on a ward and died, an inquest heard.
The inquest into the death of Audrey Keyland, of Broomhayes, Ipswich, heard that she died from pressure on her brain as a result of a blood clot a day after she had a fall.
Even though her death could not have been prevented, if tests had been carried out on her brain following the fall her family could have been at her side when she died, Greater Suffolk coroner Dr Peter Dean said.
Dr Martin Grimmer, consultant physician at Ipswich Hospital, told Dr Dean: “We do need to have a policy in place to ensure this sort of tragedy doesn't happen again.”
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Mrs Keyland, 78, was admitted to hospital on October 6 last year with chest pains.
On October 10, while still in hospital, she had a fall, and when staff rushed over to assist her, she told them that she went to put her hand on the bar of the bed but missed and fell on the floor.
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At 4.20am on October 11, staff found she had no pulse prompting efforts to resuscitate her, but she was pronounced dead less than half an hour later.
Dr Sarah McCracken told the inquest, which was held at South East Suffolk Magistrates' Court on Wednesday, that she failed to undertake any neurological observation tests, which is not normally required if a patient remains conscious after a fall, but would have been necessary in this situation due to Mrs Keyland's condition.
Dr McCracken said: “When it came to writing my plan, I forgot that aspect of care (of neurological observations) as I had been concentrating on the heart and lungs.
“The problem of relying on one individual is that every so often people make mistakes. I made a mistake in this situation. It would have been very useful to be alerted about these tests by other of members of the team.”
Dr Dean said: “Even if the tragedy could not have been prevented, the family could have been notified at an earlier stage, which would have given them a chance to be there. There are lessons to be learned.”
Brian Keyland, Mrs Keyland's son, added: “The hospital has got some key actions to take forward and we put our faith in the NHS Trust to do that.”
The coroner recorded a verdict of accidental death.