Coroner's concerns over communication at hospital where 79-year-old woman died after a fall
PUBLISHED: 14:03 11 December 2018 | UPDATED: 14:03 11 December 2018
A coroner has expressed concern about communication at a Suffolk hospital where a 79-year-old woman died after falling on a ward there.
An inquest at Norfolk Coroners Court heard on Tuesday (December 11) that Sheila Coley had been given diazepam after arriving at West Suffolk Hospital in Bury St Edmunds but this information was not passed on to nurses on the ward where she later fell and broke her hip.
Jacqueline Lake, Senior Coroner for Norfolk, also expressed concern that the hospital has not indicated whether or not any action has been taken since Mrs Coley’s death to improve communication when patients are being handed over.
Mrs Coley, of Castle Street, Thetford, died on July 8 last year at the hospital.
The inquest heard that on June 21 last year she was taken to the hospital, feeling confused, and was given diazepam to help her calm down.
At 1am, Mrs Coley was taken from A&E to a ward, where there was a short verbal handover. The nurse in charge of the ward, Emma Nunn, said she was not told that Mrs Coley was confused or had been given diazepam.
The inquest heard that the ward was short-staffed and none of the nurses had the time to look at the patients’ records.
A doctor examined her at 1.22am, concluding that she was “not oriented in space and time”, but did not pass this information verbally to the nurses, the inquest was told.
Just before 3am, Ms Nunn heard a loud bang. Mrs Coley had fallen in the ward and broken her hip.
She had an operation on June 23 and initially recovered well but her condition deteriorated and she developed a chest infection, dying on July 8.
The coroner said her conclusion was that Mrs Coley died as a result of her injury.
Previously, the inquest had heard from Rowan Proctor, executive chief nurse at the hospital, who said that, since Mrs Coley’s death, patients are now assessed on risk of falling within fifteen minutes of arriving on a ward.
She also said that efforts have been made to recruit and attract more staff.
The coroner spoke of her concern regarding communication at the hospital, especially at handover time.
“It’s clear hospital wards are very busy,” Ms Lake said. “Staff don’t have the time to look at complete records. It is important handover is properly carried out.”
She was concerned Mrs Coley had died 18 months ago and there was no indication any action had yet been taken with regard to improving communication at handover, the inquest heard.
The coroner said she will write a letter to the hospital, asking for details on action being taken to improve the handover, and the hospital must reply by December 21.
Speaking after the inquest, Mrs Coley’s daughter, Lucy Wheatley, 47, said her mother was the “most genuinely kind and caring person you could meet”.
“In Thetford we had a regular homeless man. Every week she’d give him £5. One Christmas she put £20 in a card and said now you go and ring your mother.”
“It made her death even more painful that it came at the hands of an institution she so respected.”
Mrs Wheatley said that when her mother was admitted to hospital the night she fell she was suffering from hallucinations. She also said that diazepam can “raise the risk of falls in elderly patients”.
But she does not blame the nurses. “In no way do I hold the nurses accountable for my mother’s death,” Mrs Wheatley said. “I sincerely feel that those nurses have been set up to fail, being expected to work in such short-staffed conditions. If anyone I hold Stephen Dunn and the board responsible.”
Mrs Coley is survived also by her grandsons Ben, 18, and Cameron, 14, and her husband, Terry, 88, who had cared for her when she was at home but could not attend the inquest.