Howell Fisher
PFD Report
Historic (No Identified Response)
Ref: 2015-0152
No published response · Over 2 years old
Response Status
Responses
0 of 2
56-Day Deadline
16 Jun 2015
Over 2 years old — no identified published response
About PFD responses
Organisations named in PFD reports must respond within 56 days explaining what actions they are taking.
Source: Courts and Tribunals Judiciary
Coroners Concerns
In the circumstances it is my statutory to report to you: _ The and duty
(1) Within the space of a month the deceased had at least 5 falls whilst deemed as high risk of falls: He was identified as requiring one to one nursing but there were many occasions when insufficient staff numbers meant that that could not be delivered, (2) There was no "handover material" at the point of transfer between the two hospitals detailing that he was at high risk of falls and further more on readmission to the Princess of Wales Hospital on the 20th November no falls risk assessment was carried out - indeed, after each successive fall in the Princess of Wales Hospital no formal assessment appears to have been undertaken: Throughout he_ remained at high risk of falls
(1) Within the space of a month the deceased had at least 5 falls whilst deemed as high risk of falls: He was identified as requiring one to one nursing but there were many occasions when insufficient staff numbers meant that that could not be delivered, (2) There was no "handover material" at the point of transfer between the two hospitals detailing that he was at high risk of falls and further more on readmission to the Princess of Wales Hospital on the 20th November no falls risk assessment was carried out - indeed, after each successive fall in the Princess of Wales Hospital no formal assessment appears to have been undertaken: Throughout he_ remained at high risk of falls
Action Should Be Taken
In my opinion action should be taken to prevent future deaths and believe you and your organisation have the power to take such action
Report Sections
Investigation and Inquest
On the 16th December 2014 commenced an investigation into the death of Howell Glyndwr Fisher: The investigation was concluded at the end of an inquest on today's date being16h April 2015. conclusion of the inquest was a narrative conclusion: 'Howell Glyndwr Fisher died from the complications of a fractured hip which he sustained when he fell at his home address on the 5" November 2014, against a background of vascular disease and respiratory problems".
Circumstances of the Death
The deceased fell at his home address on the 5th November 2014. He was admitted to the Princess of Wales Hospital where his hip was surgically repaired Following the surgery he developed an Ischemic left leg and was moved to Morriston Hospital in Swansea for vascular surgery _ He was unwell on arrival suffering with Atrial Fibrillation and Pneumonia and Chronic Kidney impairment He underwent surgery at Morriston which was successful and was then discharged back to the Princess of Wales Hospital on the 20" November: He developed further pneumonia; continued to deteriorate passed away on the glh December on ward 6 Whilst at Morriston Hospital he sustained two falls (no injuries sustained) and on transfer back to the Princess of Wales Hospital he sustained a further three falls (only a minor injury received) on the last fall on the 4th December 2014
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.