A “systemic failure” in South Tyneside Hospital contributed to the death of a pensioner who fractured his skull in a fall in the accident and emergency department, a coroner has ruled.
John Lawrenson, 85, was taken to the 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.
The hearing, before South Tyneside coroner Terence Carney, heard Mr Lawrenson still hadn’t been seen by a doctor when he fell over in he 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.
It was not made clear what the actual procedure was.
Mr Kumar later told the hearing that no training was implemented because, while the new system was a slightly different way of working, the process of patients being seen by a nurse and a folder being prepared for the doctor was not new and had been in place since he began working at the hospital.
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 was seen by nurse manager Julie Russell at 3.35pm, who gave him a ‘10-minute priority’, but Mr Kumar says he was not aware of his prescence on the unit until after the arrival of another patient at 3.41pm.
Mr Kumar says he was busy dealing with this patient, who had been in a car crash, and other patients on the unit, as well as assisting other doctors by looking at X-rays and signing a DNAR order.
Mr Lawrenson 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: “The matter that is concerning me is this man arrived at 3.25pm, he is assessed at 3.35pm to be seen within 10 minutes but he is not.
“It appears that other people are coming in and John, not to put a fine a point on it, is out of sight, out of mind. No one is attending him.”
He added: “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.”
Karen Sheard, clinical business manager for urgent care at South Tyneside Foundation Trust, said she was asked to investigate Mr Lawrenson’s fall to determine how it had happened and what could be done to ensure it doesn’t happen again.
She said: “I believe we failed Mr Lawrenson by nursing him from behind closed curtains.”
She also said that staff had “sadly learned the hard way” and that they had been upset by Mr Lawrenson’s death.
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.