Ethel Cross
PFD Report
Historic (No Identified Response)
Ref: 2013-0362
No published response · Over 2 years old
Response Status
Responses
0 of 1
56-Day Deadline
31 Dec 2013
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
Coroner's Concerns
and 22nd_ aged 22na end years.
At the conclusion of the inquest; indicated to the Properly Interested Persons that proposed to write to the Trust by way of a report in accordance with the provisions of paragraph of Schedule 5 of the Coroners and Justice Act 2009. During the Inquiry, received evidence that chairs Utilised by staff which have wheels attached to them had been present on ward 4 and that Ethel Cross had sat on one of these chairs which slipped and she suffered a fracture_ heard evidence that these chairs have been removed from two wards including on which elderly patients at significant risk of falls may be cared for. am concerned that such chairs may continue to be present on other wards within the Trust where such patients may have access to them and similar incidents may occur. During the course of the evidence heard that although at high risk of falls, and someone who would need one to one assistance from staff when mobilising; Ethel Cross was not provided with an alarm that in the event of her moving when staff are not nearby could alert members of the medical staff to such movement allowing the staff to attend to her. All such alarms on the ward were in use and such alarms are rarely not deployed. Having concluded this inquest, now write to the Trust to confirm that in my view the Trust should take action because: the presence of such chairs with wheels attached - in an area frequented by elderly patients may lead to further such fatalities should elderly patients access them patients who are at high risk of falls may try t0 mobilise themselves unsupported when staff are busy elsewhere on the ward with other patients and all of the available alarms are in use would therefore be obliged if the Trust would write to me in due course to confirm what steps if any the Trust proposes to take to address_these _two areas of concern
At the conclusion of the inquest; indicated to the Properly Interested Persons that proposed to write to the Trust by way of a report in accordance with the provisions of paragraph of Schedule 5 of the Coroners and Justice Act 2009. During the Inquiry, received evidence that chairs Utilised by staff which have wheels attached to them had been present on ward 4 and that Ethel Cross had sat on one of these chairs which slipped and she suffered a fracture_ heard evidence that these chairs have been removed from two wards including on which elderly patients at significant risk of falls may be cared for. am concerned that such chairs may continue to be present on other wards within the Trust where such patients may have access to them and similar incidents may occur. During the course of the evidence heard that although at high risk of falls, and someone who would need one to one assistance from staff when mobilising; Ethel Cross was not provided with an alarm that in the event of her moving when staff are not nearby could alert members of the medical staff to such movement allowing the staff to attend to her. All such alarms on the ward were in use and such alarms are rarely not deployed. Having concluded this inquest, now write to the Trust to confirm that in my view the Trust should take action because: the presence of such chairs with wheels attached - in an area frequented by elderly patients may lead to further such fatalities should elderly patients access them patients who are at high risk of falls may try t0 mobilise themselves unsupported when staff are busy elsewhere on the ward with other patients and all of the available alarms are in use would therefore be obliged if the Trust would write to me in due course to confirm what steps if any the Trust proposes to take to address_these _two areas of concern
Action Should Be Taken
In my opinion action should be taken to prevent future deaths and believe you [ANDIOR your organisation] have the power to take such action_
Report Sections
Investigation and Inquest
On April 2013 an investigation commenced into the death of Ethel Cross, The investigation concluded at the of the inquest on October 2013_ The record of the inquest confirmed as follows: The Medical cause f death was Ia Fat Embolism Ib Fractured Neck of Femur II Chronic Heart Failure and Coronary Heart Disease The conclusion of the Coroner as to the death was Accidental Death
Circumstances of the Death
Ethel Cross had a history of falls_ On 12th April 2013 at 0630 hours who had a history of falls, fell whilst returning from the bathroom on ward 4 at the Clifton Hospital. She sat on a chair for a rest The chair slipped. She suffered a fracture of her neck of femur: Initially, she was not noted to be in pain. She later did complain of pain and was therefore taken to Blackpool Victoria Hospital She died on the 13"h April 2013
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.