Hospital should 'take action' after fall death
A coroner has told a north London NHS trust it displayed "widespread communication issues" after an elderly patient died from an unwitnessed fall at a hospital.
Carl Eastman, 96, suffered an irreversible bleed on the brain after falling in the enhanced care bay of the Royal Free Hospital in Camden on 28 July last year.
An inquest into his death at Inner North London Coroner's Court heard Mr Eastman had been admitted to the hospital five days earlier following a fall at home, but he fell again in a hospital ward on 25 and 28 July.
The Royal Free London NHS Foundation Trust has been contacted for a response.
Mr Eastman was transferred to the hospital's enhanced care bay "where he should have been kept under constant observation", assistant coroner Ian Potter said in a prevention of future deaths report.
His third unwitnessed fall, in the early hours of 28 July, occurred "at a time when a member of staff should have accompanied him", the coroner said.
Mr Potter added there was "evidence of what I considered to be 'widespread communication issues' in the care provided to Mr Eastman" which posed "a risk that future deaths could occur unless action is taken".
This included staff on the ward incorrectly telling the on-call doctor on 28 July that nobody had fallen which meant Mr Eastman's condition was not reviewed, he continued.
Communication between the ward staff and medical staff was "not good" and evidence provided at the inquest revealed there were "deficiencies in basic record keeping", the coroner added.
Mr Potter said: "There was clear evidence that the trust has put extensive measures in place to address the issue of staff having not followed the trust's own post-fall procedures and protocols.
"However, I am concerned that the issue may not be limited to just those particular protocols and may be indicative of a wider skills or knowledge deficit."
Evidence also appeared to show "a lack of professional curiosity on the part of some staff members", he added.
Copies of the coroner's Prevention of Future Deaths Report were sent to the chief executive of the Royal Free London NHS Foundation Trust, Mr Eastman's family and the Care Quality Commission.
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