Pensioner's death might have been prevented, says Suffolk coroner
The death of a vulnerable pensioner who suffered a fatal bleed on the brain after falling at home might have been prevented, a coroner ruled.David Thomas Bendell died on 13 July 2024 at the age of 79, five days after being discharged from The West Suffolk Hospital, in Bury St Edmunds, Suffolk.Mr Bendell, who had blood cancer and was not able to walk well following a stroke, had been deemed well enough to go home.Suffolk coroner Nigel Parsley has now filed a Prevention of Future Deaths Report, suggesting the pensioner was "placed at risk" by being sent home when it was "not safe to do so".
During an inquest, Mr Parsley concluded Mr Bendell's death was an accident contributed to by his underlying ill health, but he voiced concerns about how he was treated in the lead up to it.The court heard how Mr Bendell had been allowed home after his stroke because he had been deemed capable of moving from his bed to a commode and back again unassisted. And because he was not considered a candidate for hospital-based rehabilitation on a specialist stroke rehabilitation ward, he could only receive further treatment at home.His family described how the ambulance team that took him home considered taking him straight back to the hospital, as they did not think he would be able to manage.
One of the first physiotherapists to see Mr Bendell following his return reportedly said "this is not going to work" to family members upon seeing him in his accommodation.Four days later, on 12 July, he was found "injured and slumped" on his sofa by his carers, having fallen over, before becoming unresponsive and suffering seizures.At hospital, a CT scan identified that he had a large bleed to his brain, which proved fatal due to the fact his blood was less able to clot because of his cancer.
'Future deaths could occur'
Mr Parsley is now calling for change after the court heard there were no "step-down community rehabilitation" facilities for patients like Mr Bendell, who, while not eligible for inpatient rehabilitation, were not capable of keeping themselves safe when at home."In my opinion, there is a risk that future deaths could occur unless action is taken," he said in his Prevention of Future Deaths Report."I am concerned that with the current rehabilitation options available being either in a specialist hospital ward or at home, other individuals in David's situation who are not deemed suitable for in-patient hospital, will also be placed at risk by being sent home when it is not safe to do so."
'Deepest sympathies'
The NHS Suffolk and North East Essex Integrated Care Board extended its "condolences to the family of Mr Bendall"."We will work with our partners to examine the findings of this report and assess the service provision," a spokesperson added.A Department of Health and Social Care spokesperson also sent its "deepest sympathies" to Mr Bendell's friends and family. "It is important we learn lessons from every prevention of future deaths report. We will consider the report carefully before responding formally," a spokesperson said.
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