A nurse from Croydon University Hospital has admitted that failings made in patient risk assessments meant that an elderly patient may not have received proper care in the lead up to his death.
Sandra Mason, a matron at the hospital’s care unit, spoke at the inquest into the death of 81-year-old Anthony Allchin, who died at the hospital on July 8 last year.
11 days before his death, Mr Allchin suffered a fractured femur (thigh bone) as a result of a fall from his hospital bed, something that ultimately led to his death.
Ms Mason explained that a mistake in Mr Allchin’s risk assessment meant that he was given a lower risk level than what he should have been given, and therefore was not cared for quite as closely as he should have been.
In the early hours of Tuesday, June 27 last year, Mr Allchin, who at the time had difficulty communicating and was confused, became agitated and had to be calmed by a nurse.
Shortly after this, a mental health nurse noticed that he had fallen to the ground from his bed, and an x-ray revealed that he had suffered a fractured femur and would need to undergo surgery as soon as possible.
Mr Allchin’s initial reason for being in hospital was that he had kidney disease, something that was slowly improving up until his fall. However, following surgery, Mr Allchin’s kidneys deteriorated further, and a post-mortem examination gave the cause of death as multi-organ failure, pneumonia and pancreatitis, for which the fall was partly responsible.
During the inquest, Ms Mason was questioned as to whether, given Mr Allchin’s advanced state of agitation, his bed should have had the bed rails raised, as these can cause further discomfort or even injury in severe cases.
“If Mr Allchin had been given the right risk assessment score, there is a possibility that the bed rails would have been lowered, as this is something we do to reduce risk of harm to agitated patients,” she said.
Eunice Goncalves, another nurse at the hospital, explained that after his fall, Mr Allchin seemed incapable of recalling his fall, saying 'no' when asked whether he had fallen.
Ms Goncalves said: “Another patient on the ward said that the bed rails were not up when Mr Allchin fell, but in the checks made shortly before, I fully believe that the rails were up.
“He complained of leg pain, and we had to use a special hoist to get him back into the bed, where, following the fall, he slept intermittently until the morning.”
Despite successful surgery on his fracture, Mr Allchin’s kidney condition worsened and, as per his family’s wishes, he was not put on dialysis as they felt it would not have given him enough quality of life.
Concluding the inquest, Coroner Sarah Ormond-Walsh said: “Mr Allchin died on July 8 of natural causes. He died from multiple organ failure, which a fall sustained shortly prior to death contributed to.”
It was accepted during the inquest that the falls risk assessment was carried out incorrectly and that a bed rails assessment was not done when it should have been.
However, a Croydon Health Services NHS Trust spokesperson highlighted that there was no evidence heard that the bed rails staying up caused Mr Allchin's agitation.
In a statement, they said: "We would like to extend our sincere sympathies to Mr Allchin’s family.
"We note the Coroner’s conclusion that Mr Allchin died from natural causes contributed to by an osteoporotic fracture sustained in a fall.
"We have fully investigated the circumstances surrounding his fall in hospital to ensure our staff are doing all they can to prevent falls and have implemented changes to minimise the risk of a similar occurrence in the future."
Source: CroydonAdvertiser