Dear Coroner Beasley-Murray, I write in the matter of the late Ann Smith in response to your recent Regulation 28 Report to prevent future deaths. Ms Smith was admitted to Princess Alexandra Hospital on 8th September 2019. On 9th September she suffered an unwitnessed fall which resulted in a head injury. She sadly died on 13th September 2019 and your inquest into her death was held on 3rd November 2020. You were concerned that ‘there was uncertainty in how to deal with the anti-coagulation aspect of Ms Smith’s care in the wake of her fall. That there was a lack of a local protocol for the management of the sub-group of patients over 65, on anticoagulants, and being given a treatment dose of clexane for another clinical reason, eg suspected pulmonary embolus, who then sustain a head trauma’. The speed at which action is taken following a fall is clearly significant, as is the importance of the patient having a clearly identified anticoagulation action plan post fall. To that end, the Trust has established a multi-disciplinary Anticoagulation/Falls Tasking Group comprising of the Associate Medical Director for the Medicine Healthcare group, the Anticoagulation Pharmacist and the Lead Nurse for Falls Prevention. This group has developed an Action Plan, a copy of which I share with you. Whilst the actions from this plan are still ongoing, I am confident that the Trust is on course to deliver the necessary changes to ensure that there are no further severe harms or deaths from this type of incident. I propose to update you again by the end of March 2021.

Dear Coroner Brookes,

Re: Ann Margaret Smith (Deceased)

I am writing to you in my role of Medical Director at The Princess Alexandra Hospital NHS Trust (PAHT) regarding the inquest into the death of Mrs Ann Smith. This inquest was heard before Senior Coroner Beasley-Murray on 3rd November 2020. In conjunction with her conclusion, Ms Beasley-Murray issued a Regulation 28 report to which PAHT responded on 30th December 2020. Part of that response promised a subsequent update would be provided to the Senior Coroner by March 2021. I have now established that this update was unfortunately not forthcoming, primarily as a result of the overwhelming priorities of the Covid wave. Please accept my sincere apologies for this oversight. Ms Smith was admitted to Princess Alexandra Hospital on 8th September 2019. The following day she suffered an unwitnessed fall which resulted in a head injury and she sadly died on 13th September 2019. Senior Coroner Beasley-Murray indicated in her Regulation 28 report that she was concerned that ‘there was uncertainty in how to deal with the anti-coagulation aspect of Ms Smith’s care in the wake of her fall. That there was a lack of a local protocol for the management of the sub-group of patients over 65, on anticoagulants, and being given a treatment dose of clexane for another clinical reason, eg suspected pulmonary embolus, who then sustain a head trauma’. The importance of the patient having a clearly identified anticoagulation action plan post fall remains a priority for PAHT. The Action Plan developed by our multi-disciplinary Anticoagulation/Falls Tasking Group continues apace and I include with this letter the previously promised update of progress with that. PAHT remains committed to ensuring that all of our clinical, nursing and allied health professional staff are fully conversant in falls prevention and falls management. Our Strategic Falls Prevention Plan for 2021/22 is focussed on continued training and oversight to ensure preventative actions.

We continue to make progress with regards to overall patient falls with harm, and I am pleased to say that we have achieved a 10% reduction during quarter 4 of 2019-20, and also in each of quarters 1 & 2 of 2021. Our goal is to reduce the number by 50% by the end of March 2022. I remain confident that the Trust is on course to deliver the necessary changes required.