Beryl Farmer
PFD Report
Partially Responded
Ref: 2016-0420
Coroner's Concerns (AI summary)
A patient at high risk of falls lacked a falls assessment, was moved to an unmonitored bay, and received inadequate post-fall neurological observations and imaging after a significant head injury.
View full coroner's concerns
1. Evidence emerged during the inquest that Mrs Farmer had a risk of a falling (moderate to high risk). There was no evidence that a falls risk assessment had been completed.
2. Given the risks of falls, there was no clear justification for moving her from a monitored bay to an unmonitored bay.
3. After the fall, only one set of neurological observations were performed before her discharge.
4. In addition no CT Head scan was performed despite evidence of significant bruising to her face and head.
2. Given the risks of falls, there was no clear justification for moving her from a monitored bay to an unmonitored bay.
3. After the fall, only one set of neurological observations were performed before her discharge.
4. In addition no CT Head scan was performed despite evidence of significant bruising to her face and head.
Responses
Action Planned
The Trust is amending its inpatient falls policy to ensure post incident monitoring is undertaken and will more clearly link standards in ED and on the wards. Face to face training time will reinforce this pathway in the months ahead and use of Vital Pac and the upcoming installation of new electronic patient record will provide decision support and alerts to reinforce standards. (AI summary)
The Trust is amending its inpatient falls policy to ensure post incident monitoring is undertaken and will more clearly link standards in ED and on the wards. Face to face training time will reinforce this pathway in the months ahead and use of Vital Pac and the upcoming installation of new electronic patient record will provide decision support and alerts to reinforce standards. (AI summary)
View full response
Dear Mr Siddique
Re: Regulation 28 Report – Beryl Farmer
I am in receipt of your Regulation 28 Report following the Inquest and your ruling on 23 November 2016, in respect of the late Mrs Beryl Farmer. I should extend again the condolences of the Trust to Mrs Farmer’s family, to whom I am copying my letter. We do not accept however that the omissions you cite directly contributed to Mrs Farmer’s death.
I note that of particular concern to you was the lack of risk assessment for falls and the absence of sustained neurological observations following her fall which resulted in significant bruising. Equally you have raised concerns regarding our lack of policy on performing CT scans on patients who have sustained a head injury with obvious visible bruising. I share those concerns and have looked into the matter personally. I have also drawn this situation to the attention of my Board operating in public. There is no ambiguity here that we need to do better. We are acting to reduce a likelihood of recurrence.
We have the necessary policies and procedures in place to manage Head Injuries which present in our Emergency Departments. Equally the management of patients who have fallen during an admission is detailed in policies and guidance for staff. These provide both advice and instruction to staff. Having had this material re-checked by our Medical Director and Chief Nurse, it meets both NICE and NPSA standards and remains suitable. It is available to staff
2 | P a g e
through our Intranet web site. Face to face training time will reinforce this pathway in the months ahead. Additionally we will issue a Patient Safety Notice (an internal safety alert) reminding staff of the importance of neurological observations and the link being made between the management of inpatient falls with a head injury and the pathway.
We are going to amend our inpatient falls policy. This will help us to ensure that post incident monitoring is undertaken. It will also more clearly link our standards in ED and on the wards. It is unacceptable that in this situation the requested monitoring was discontinued. Our use of Vital Pac and the upcoming installation of our new electronic patient record by Christmas 2017 will provide decision support and alerts to reinforce our standards. These changes will be complete by the end of March 2017.
Of course, policies and standards are only functional within a culture which prizes them. As colleagues from NHS England and the CQC are aware, we are currently undertaking work across our medical wards to try and ensure standards are raised. This is based on multi professional team based working, and looking to create a safety culture which is grounded in continuous improvement. This includes, but is not limited to, changed accountabilities at local level, ward based quality improvement time, and monitored board rounds for clinicians to challenge each other’s practice. These culture changes take time but the next 12 weeks will see intensive work to try and make the right start.
My colleague, , Assistant Director of Governance, would be best placed to provide advice to your office on the detail of our plans or indeed to provide such updates as are required on our progress this year. She can be reached on
Re: Regulation 28 Report – Beryl Farmer
I am in receipt of your Regulation 28 Report following the Inquest and your ruling on 23 November 2016, in respect of the late Mrs Beryl Farmer. I should extend again the condolences of the Trust to Mrs Farmer’s family, to whom I am copying my letter. We do not accept however that the omissions you cite directly contributed to Mrs Farmer’s death.
I note that of particular concern to you was the lack of risk assessment for falls and the absence of sustained neurological observations following her fall which resulted in significant bruising. Equally you have raised concerns regarding our lack of policy on performing CT scans on patients who have sustained a head injury with obvious visible bruising. I share those concerns and have looked into the matter personally. I have also drawn this situation to the attention of my Board operating in public. There is no ambiguity here that we need to do better. We are acting to reduce a likelihood of recurrence.
We have the necessary policies and procedures in place to manage Head Injuries which present in our Emergency Departments. Equally the management of patients who have fallen during an admission is detailed in policies and guidance for staff. These provide both advice and instruction to staff. Having had this material re-checked by our Medical Director and Chief Nurse, it meets both NICE and NPSA standards and remains suitable. It is available to staff
2 | P a g e
through our Intranet web site. Face to face training time will reinforce this pathway in the months ahead. Additionally we will issue a Patient Safety Notice (an internal safety alert) reminding staff of the importance of neurological observations and the link being made between the management of inpatient falls with a head injury and the pathway.
We are going to amend our inpatient falls policy. This will help us to ensure that post incident monitoring is undertaken. It will also more clearly link our standards in ED and on the wards. It is unacceptable that in this situation the requested monitoring was discontinued. Our use of Vital Pac and the upcoming installation of our new electronic patient record by Christmas 2017 will provide decision support and alerts to reinforce our standards. These changes will be complete by the end of March 2017.
Of course, policies and standards are only functional within a culture which prizes them. As colleagues from NHS England and the CQC are aware, we are currently undertaking work across our medical wards to try and ensure standards are raised. This is based on multi professional team based working, and looking to create a safety culture which is grounded in continuous improvement. This includes, but is not limited to, changed accountabilities at local level, ward based quality improvement time, and monitored board rounds for clinicians to challenge each other’s practice. These culture changes take time but the next 12 weeks will see intensive work to try and make the right start.
My colleague, , Assistant Director of Governance, would be best placed to provide advice to your office on the detail of our plans or indeed to provide such updates as are required on our progress this year. She can be reached on
Sent To
- Care Quality Commission-
- Sandwell and West Birmingham Hospital NHS Trust
Response Status
Linked responses
1 of 2
56-Day Deadline
20 Jan 2017
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 the 7 September 2016, I commenced an investigation into the death of the late Mrs Beryl Farmer. The investigation concluded at the end of the inquest on 23 November 2016. The conclusion of the inquest was a short narrative conclusion of: Accidental death contributed to by neglect. The cause of death was:
1a Subdural Haemorrhage
II Ischaemic Heart Disease, Hypertension, Left Ventricular Failure, Atrial Fibrillation, Type 2 Diabetes Mellitus, Chronic Kidney Disease
1a Subdural Haemorrhage
II Ischaemic Heart Disease, Hypertension, Left Ventricular Failure, Atrial Fibrillation, Type 2 Diabetes Mellitus, Chronic Kidney Disease
Circumstances of the Death
1. Mrs Farmer was a 77 year old woman with a medical history including chronic kidney disease, ischaemic heart disease, hypertension, diabetes, dextrocardia and situs inversus. She was admitted to Sandwell Hospital on the 20 June 2016 after experiencing symptoms of loss of appetite, weight loss and nausea.
2. She was diagnosed with severe hypocalcaemia secondary to severe vitamin D deficiency. She also had significant postural hypotension with a drop of 25mmHg on standing. She received intravenous calcium infusions for treatment.
3. On the 23 June shortly after 6am she had a fall from her bed and sustained an injury to her face and head. This resulted in bruising to her right eye area and her forehead. No CT scan was performed at this stage because it was concluded that her GCS was 15/15 and no evidence of vomiting, and her key observations were normal.
4. She was later discharged on the 24 June 2016. No documentation for a falls risk assessment was available or had been completed.
5. In addition a decision had been taken to move her from a monitored area to a de-monitored area prior to the fall without consultation with the medial team.
[IL1: PROTECT]
6. There was also a failure to perform further neurosurgical observations after the first set of observations before discharge.
7. At home, her condition declined and she developed headaches and was readmitted back to Sandwell Hospital on the 1 July 2016. A CT scan was performed on this occasion and a subdural haemorrhage diagnosed.
8. Advice from neurosurgeons was sought and she was managed conservatively. She then effectively remained in Hospital and went on to develop seizures as a result of the subdural haemorrhage and sadly died on the 30 August 2016.
2. She was diagnosed with severe hypocalcaemia secondary to severe vitamin D deficiency. She also had significant postural hypotension with a drop of 25mmHg on standing. She received intravenous calcium infusions for treatment.
3. On the 23 June shortly after 6am she had a fall from her bed and sustained an injury to her face and head. This resulted in bruising to her right eye area and her forehead. No CT scan was performed at this stage because it was concluded that her GCS was 15/15 and no evidence of vomiting, and her key observations were normal.
4. She was later discharged on the 24 June 2016. No documentation for a falls risk assessment was available or had been completed.
5. In addition a decision had been taken to move her from a monitored area to a de-monitored area prior to the fall without consultation with the medial team.
[IL1: PROTECT]
6. There was also a failure to perform further neurosurgical observations after the first set of observations before discharge.
7. At home, her condition declined and she developed headaches and was readmitted back to Sandwell Hospital on the 1 July 2016. A CT scan was performed on this occasion and a subdural haemorrhage diagnosed.
8. Advice from neurosurgeons was sought and she was managed conservatively. She then effectively remained in Hospital and went on to develop seizures as a result of the subdural haemorrhage and sadly died on the 30 August 2016.
Action Should Be Taken
1. You may wish to consider further training for all those involved in this incident in respect of requirements for managing risks of falls.
2. In addition you may consider it is prudent in light of this incident to review your policy on performing CT head scans particularly for those patients where there is evidence of bruising to the head area.
2. In addition you may consider it is prudent in light of this incident to review your policy on performing CT head scans particularly for those patients where there is evidence of bruising to the head area.
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.