UK Inquiry Tracker

William Beckwith

PFD Report All Responded Ref: 2014-0258

Date of Report 9 June 2014

Coroner Robert Hunter

Coroner Area Derby & Derbyshire

Response Deadline est. 4 August 2014

Hospital Death (Clinical Procedures and medical management) related deaths

Judiciary.uk Report PDF

All 1 response received · Deadline: 4 Aug 2014

Coroner's Concerns (AI summary)

A frail, elderly patient with a history of falls was discharged home in the early morning without formal assessment of his or his wife's abilities, home environment, or essential post-discharge care needs.

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A 91 year old patient, with a history of falls and who had attended A&E due to a fall was discharged home at 04:17 hours in the early morning to his elderly wife. There was no formal assessment as to his abilities, the home environment or his wife’s abilities to look after him. No consideration was given to post discharge planning or assessment of needs such as district nurse or social care follow up. The Department, at that time, did not have in place any formal policy or procedure for risk assessing the safety of discharging a frail, elderly patient to home in the early hours of the morning.

Responses

Response

23 Jul 2014

Action Planned
The hospital is undertaking a multidisciplinary review of its guidance for assessing elderly patients after a fall, with a clear policy expected by the end of August. (AI summary)

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Dear Dr Hunter Re: Regulation 28 Report to Prevent Future Deaths following the inquest into the death of William Leonard Beckwith Further to my letter dated 13th June 201_ Iam now in position to offer you our substantive response to the concerns you raised in your Regulation 28 report relating to the above gentleman There has been guidance for staff within the Emergency Department since 2012 in relation to the assessment of elderly patients presenting to the department following a fall: The guidance in the form of a flow chart was intended to assist staff in conjunction with their clinical assessment to determine whether or not the patient required admission or could be discharged. However; in light of your letter a multidisciplinary review of this document is currently in progress with in from senior nursing staff, and care of the elderly physicians within the Medicine & Emergency Care Division. The result of this review will be a clear policy for staff to follow which expect to be finalised by the end of August: Once the policy has been ratified, will provide you with a copy for your information. hope that you can see that we have taken your recommendations seriously, but if you have any further concerns or queries in relation to this matter please do not hesitate to contact me.

Sent To

Chesterfield Royal Hospital

Response Status

Linked responses 1 of 1

56-Day Deadline 4 Aug 2014

All responses received

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

On18th October 2013 I commenced an investigation into the death of William Leonard Beckwith, 91 years old. The investigation concluded at the end of the inquest on 10th April 2014. The conclusion of the inquest was one of Accidental Death.

The medical Cause of Death being:

1a. Gastro-intestinal tract haemorrhage. 1b. Duodenal Ulcer

II. Cervical spine fracture (treated), Acute stress ulceration, Bronchopneumonia

Circumstances of the Death

On the 13th September 2013 William Leonard Beckwith sustained a fracture to his cervical spine resulting from a fall at home. He attended the accident and emergency department of the Chesterfield Royal Hospital. Medical and Nursing staff were aware of a history of previous falls. Reduced range of movement of his cervical spine was noted at that time, however his fracture was not diagnosed and he was discharged home at 04:17 hours in the morning. He was readmitted with acute stridor on the 15th September 2013 caused by a blood clot from the cervical fracture compressing his wind pipe. Despite management in intensive care and on the ward he continued to deteriorate and died on the 11th October 2013. From the evidence heard at inquest, on the balance of probabilities, earlier diagnosis of the fracture would not have affected the outcome.