UK Inquiry Tracker

John Wherlock

PFD Report Historic (No Identified Response) Ref: 2018-0089

Date of Report 28 March 2018

Coroner Robert Sowersby

Coroner Area Avon

Response Deadline ✓ from report 23 May 2018

Hospital Death (Clinical Procedures and medical management) related deaths

Judiciary.uk Report PDF

Coroner's Concerns (AI summary)

Simultaneous staff breaks led to insufficient ward cover and unsupervised patients, directly resulting in a fall; this unsafe staffing practice was still ongoing despite being criticised.

View full coroner's concerns

_ (1) was told in evidence that at the time of the accident the was being covered by two nurses two nursing assistants (ie, by 4 staff), but that two of those staff had taken their 1-hour break at the same time; effectively leaving the ward with very little cover. The fall had then occurred when a nursing assistant left the deceased's bay to help another member of staff to change a bed (leaving entirely unsupervised): (2) While would be concerned in any event that staff had taken their breaks at the same time given the effect that that would inevitably have on the remaining nurses' ability to cope with the patients on was even more concerned when the nursing assistant who gave live evidence at the inquest told me that this was practice which was still taking place; despite it having been highlighted and criticised in the serious untoward incident report:

Sent To

Bristol NHS Trust

Response Status

Linked responses 0 of 1

56-Day Deadline 23 May 2018

About PFD responses

Organisations named in PFD reports must respond within 56 days explaining what actions they are taking.

Source: Courts and Tribunals Judiciary

Report Sections

Investigation and Inquest

On 30th 2017 an investigation into the death of John Frederick Wherlock, aged 90 years, was commenced. The investigation concluded at the end of the inquest on 23rd February 2018. The conclusion of the inquest was as follows: The medical cause of death was recorded as 1a) Gastrointestinal bleed
2) Hip fractures (operated), frailty, chronic kidney disease The narrative conclusion was recorded as: Mr Wherlock already had a fractured and was at a high risk of further falls. He was left unsupervised and fell again, suffering a second fracture: Sadly his condition deteriorated and he died in Bristol Royal Infirmary on 23 May 2017 .

Circumstances of the Death

The deceased was an inpatient on Ward 518 at the BRI He was elderly and confused, had already suffered a fractured hip in one fall, and was at a high risk of further falls. He was left unsupervised during that time tried to get out of bed: he fell again, fracturing his hip on the other side, and that fracture contributed to his subsequent death Telephone 01275 461920 Email AvonCoronersTeam@bristol gov.uk Website Www.avon-coroner.com The Coroner's Court; Old Weston Road, Flax Bourton, BS48 1UL May hip and

Action Should Be Taken

In my opinion action should be taken to prevent future deaths and believe you have the power to take such action.

Copies Sent To

coroner.com The Coroner's Court; Old Weston Road, Flax Bourton, BS48 1UL ward and him the ward You may

Inquest Conclusion

The medical cause of death was recorded as 1a) Gastrointestinal bleed
2) Hip fractures (operated), frailty, chronic kidney disease The narrative conclusion was recorded as: Mr Wherlock already had a fractured and was at a high risk of further falls. He was left unsupervised and fell again, suffering a second fracture: Sadly his condition deteriorated and he died in Bristol Royal Infirmary on 23 May 2017 .