Ian Page
PFD Report
Historic (No Identified Response)
Ref: 2014-0403
Coroner's Concerns (AI summary)
Communication failures post-handover, lack of falls risk assessment, unavailability of a low bed, and inadequate staffing levels for high-need patients contributed to risks.
View full coroner's concerns
1. There was a training need identified regarding communication following patient handover.
2. No risk assessment was carried out on Mr Page identifying the risk of falls.
3. There was no low bed available to Mr Page.
4. A review of the provision of nursing staff was identified when patient circumstances require greater staffing levels. 2
2. No risk assessment was carried out on Mr Page identifying the risk of falls.
3. There was no low bed available to Mr Page.
4. A review of the provision of nursing staff was identified when patient circumstances require greater staffing levels. 2
Sent To
- Withybush General Hospital
Response Status
Linked responses
0 of 1
56-Day Deadline
7 Nov 2014
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 6th May 2014 I commenced an investigation into the death of Ian Page then aged 86. The investigation concluded at the end of the inquest on 12th September 2014. The conclusion of the inquest was one of accidental death. The medical cause of death was: 1(a) fracture of cervical spine 1(b) ischaemic heart disease, fracture of left hip
Circumstances of the Death
(1) Mr Page was admitted to Withybush General Hospital on 26th April 2014 following a fall at home. (2) He underwent surgery at the Hospital. Following the operation Mr Page remained in hospital. Mr Page had dementia and would make repeated attempts to leave his bed despite his recent surgery. (3) On the 28th April at approximately 23.10 hours he got up from his bed and fell fracturing his cervical spine. (4) His condition deteriorated and he died on the 2nd May 2014.
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.