NHS trust warned of ‘widespread communication issues' after man died from fall
A coroner has told an NHS trust it displayed 'widespread communication issues' after an elderly patient died from an unwitnessed fall at one of its hospitals.
Carl Eastman, 96, suffered an irreversible bleed on the brain after falling in the Enhanced Care Bay of the Royal Free Hospital in Camden, north London, on July 28 last year.
An inquest into his death heard Mr Eastman had been admitted to the hospital five days earlier following a fall at home and that he fell again while in a hospital ward on July 25, although neither incident resulted in significant injury.
He was then transferred to the Enhanced Care Bay 'where he should have been kept under constant observation', said Ian Potter, assistant coroner for inner north London, and his third unwitnessed fall in the early hours of July 28 occurred 'at a time when a member of staff should have accompanied him'.
The hospital is run by the Royal Free London NHS Foundation Trust, along with three other hospitals in London and Hertfordshire.
The coroner said there was 'evidence of what I considered to be 'widespread communication issues' in the care provided to Mr Eastman', including staff on the ward incorrectly telling the on-call doctor on July 28 that nobody had fallen, meaning Mr Eastman was not reviewed.
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 said.
He said evidence appeared to show 'a lack of professional curiosity on the part of some staff members' and the possibility of an underlying skills or knowledge deficit at the hospital.
The coroner added: 'In my opinion action should be taken to prevent future deaths.'
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.
The trust has been contacted for comment.
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