Coroner attacks Pennine Acute Trust falls-risk policy

Coroner Simon Nelson has criticised the way patients at the Pennine Acute Trust are deemed at risk of falls following an inquest into the death of 77-year-old John Hooper, of Mellalieu Street, Middleton.

Speaking at the resumption of an inquest adjourned last August, Mr Nelson called risk assessment procedures for vulnerable patients in hospital “inadequate”.

He called for procedures to be revised and an update to be sent to him in six months’ time.

John Hooper, of Mellalieu Street, Middleton, fell while going to the toilet on ward F5 at the Royal Oldham Hospital in the early hours of 13 January last year. He banged his head and died the following day.

The inquest was adjourned to allow the trust, which runs hospitals in Rochdale, Oldham, Bury and North Manchester, to answer criticisms from Mr Hooper’s partner, Patricia Green.

At the previous hearing she said a senior nurse told her that Mr Hooper, who had difficulty walking, went past the nurses’ station using two walking sticks and no one offered to help. Moments later, he fell, an accident witnessed by nurses.

Yesterday, the inquest heard that Mr Hooper was admitted to the Royal Oldham Hospital in December 2008, for bowel surgery and was then put on F5 ward, where patients have a buzzer next to their bed and are told to use it if they need assistance from nurses.

A report by colorectal consultant Antony Rate said he believed Mr Hooper had slipped and suffered a brain haemorrhage, which was accidental and not preventable.

Sister Christine Nixon, F5 ward manager, said no falls risk assessment could be found relating to the time of Mr Hooper’s admission but a retrospective assessment was done before he underwent surgery.

She said: “From what I can gather, because the physiotherapist told him he could walk unaided, he got himself out of bed and set off to walk to the toilet.”

She said no one had seen him get out of bed, but the trust was unsure if any staff member had asked him if he needed assistance.

Mr Nelson said he found it surprising that Mr Hooper was not deemed at high risk of falling considering his age, the fact that he had undergone surgery and that he was on the anticoagulant drug Warferin.

Mrs Green, from Bolton, said she believed there were shortcomings in the attitude to Mr Hooper’s care.

She said: “It is difficult as a lay person to weed out whether it was down to normal procedures adhered to at the time or whether proper procedures were not in place. I certainly feel there were people around who may have offered help, whether it was asked for or not.”

In his summing up, Mr Nelson said: “I’m disappointed that while on route to the toilet that as a matter of course and out of respect for his dignity, Mr Hooper wasn’t offered assistance.

“But that is very different from me reaching a conclusion that there was actual neglect in terms of the nursing staff concerned.”

Mr Nelson gave a verdict that Mr Hooper died from injuries sustained following a fall/collapse on 13 January while a patient on ward F5 at the Royal Oldham Hospital.

He was assured that the trust’s falls assessment policy was being revised but he said that in the meantime, he hoped assessments would be completed on admission and at regular intervals thereafter.

He added: “I hope lessons have been learned.”