Nellie Travis

PFD Report Historic (No Identified Response) Ref: 2014-0101
Date of Report 5 March 2014
Coroner John Pollard
Coroner Area Manchester (South)
Response Deadline est. 30 April 2014
Hospital Death (Clinical Procedures and medical management) related deaths
Judiciary.uk Report PDF
Coroner's Concerns (AI summary)
The hospital's Falls Risk Assessment tool is ineffective due to its subjective nature and inconsistent application by nursing staff, highlighting the need for a more objective assessment method.
View full coroner's concerns
During the course of the evidence was told that there is a Falls Risk Assessment tool used by the hospital; but in this case it had been completed and assessed by a 'bank nurse' who was not an employee of the Trust: The evidence given by the senior member of the nursing staff was to the effect that the operation of the Falls Risk Assessment Tool is very subjective and depends upon an individual opinion of the nurse completing it as to how high the falls risk is shown to be. It was agreed that such a document is of very little use at all and that a more objectively assessed tool needs to be adopted.
Sent To
  • Tameside Hospital NHS Foundation Trust
Response Status
Linked responses 0 of 1
56-Day Deadline 30 Apr 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 14th October 2013 commenced an investigation into the death of Nellie Travis, date of birth 13th March 1927 The investigation concluded on the 28th February 2014 and the conclusion was Accidental Death: The medical cause of death was 1a Haemorrhagic cerebral infarction and 2 Pneumonia, fractured neck of femur sustained following a fall, chronic bronchitis and emphysema, idiopathic anaemia_
Circumstances of the Death
She was admitted to hospital for the problem of her anaemia. On the 2nd October 2013 she was rising from her bed in the hospital ward when she fell and broke her hip.
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. It is essential that full information is passed promptly to the GP practice of a patient discharged. being
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.