Hospital bosses have pledged that lessons will be learned after a coroner ruled that “systemic failure” led to the death of a pensioner who fell and fractured his skull after being left unattended for an hour.
John Lawrenson, 85, was taken to South Tyneside District Hospital on November 2, last year, after a suspected fall at his home in Ingham Grange, South Shields, and assessed as needing to be seen by a doctor within 10 minutes.
An inquest led by South Tyneside coroner Terence Carney, heard Mr Lawrenson still hadn’t been seen by a doctor when he fell over in the hospital’s Rapid Assessment and Treatment Unit an hour later – because a doctor and nurses were not working to the same monitoring procedure.
The inquest heard that procedures at the hospital had changed on October 10, last year, but that no training was given to staff.
Nurses believed that they were to assess a patient and leave a folder with their findings on a desk for the doctor to pick up.
However, Mr Anil Kumar, the A&E consultant on shift, said his understanding of the system was that nurses were to come to him to alert him of the arrival of patients and when they needed to be seen.
Dr Shaz Wahid, South Tyneside NHS Foundation Trust’s medical director
It was not made clear what the actual procedure was.
The confusion meant Mr Kumar didn’t see Mr Lawrenson until after he fell an hour later.
The fall fractured his skull and caused a bleed. He died of a blunt head injury.
The hearing heard Mr Lawrenson arrived in the department at about 3.25pm and fell through the curtain of his cubicle at about 4.35pm, suffering the fatal injury. He was then taken for a CT scan but suffered a cardiac arrest. He then suffered another cardiac arrest and died at 6.47pm.
Mr Carney said: “This man has a head injury and needs someone planning for that injury and nobody is. The fact of the matter is this man was a priority and he should have been seen sooner than at the point when he fell on the floor. That’s the simple truth.”
Mr Carney recorded the cause of death as a blunt head injury sustained in a fall at the hospital.
He said: “As concerned as I am to the circumstances of this case, I do not think it goes far enough as to be neglect.”
He gave his conclusion, saying: “John’s death was an accidental death but contributed to by a systemic failure to address and manage his care needs.”
He said he intended to write to South Tyneside Foundation Trust as to how he thought the policy surrounding the procedure in the unit could be enhanced in light of this case.
South Tyneside NHS Foundation Trust’s medical director, Dr Shaz Wahid, said: “We extend our deepest sympathies to Mr Lawrenson’s family on their sad loss. Patient safety is our main priority and we have already conducted our own investigation into the circumstances around Mr Lawrenson’s death and have implemented actions as a result to prevent such a tragedy ever happening again.
“We will be looking closely at the coroner’s findings, which we fully accept, to ensure that we take on board any further lessons to be learned.”