Fall death leads to reforms at hospital

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THE DEATH of an elderly man after two serious falls in hospital has prompted extensive reforms after his family raised concerns about his care.

Raymond Hack, 89, died at Worthing Hospital on April 29, 2013, after two falls on Brooklands ward in two days.

An inquest into his death at Centenery House, in Durrington, on Thursday, heard that a risk assessment form had not been updated following his first fall, while his family had unanswered questions about his care.

A letter to the hospital by Mr Hack’s son, David, read: “My aim is to ascertain the true facts surrounding my father’s death and that those culpable will learn from and accept responsibility for their mistakes.

“To know my father met such a violent end in your hospital has had a devastating effect.”

Mr Hack, of Small Dole, near Steyning, was admitted to the ward on April 12.

He was an unwilling patient, concerned only with his poor hearing. He remained in hospital while decisions on his ongoing care were made, with a residential placement discussed.

On April 25, he fell for the first time and his condition worsened throughout the day.

Ward sister Samantha Jackson said: “As the evening went on, we found him getting more unreasonable and he started to become quite comatose.

“I had to go and tell his wife, who was also in hospital, that he wasn’t very well.

“We put them together as we didn’t think he was going to survive but the next morning he was reading his newspaper, telling us to leave him alone and go away.”

The inquest heard how staff were distressed about the incident and had not immediately updated Mr Hack’s falls risk assessment, having stayed late to monitor his condition.

After his apparent recovery, Mr Hack fell again during the following night, which left him unconscious until his eventual death.

Reflecting on what could be done differently in future, Sister Jackson said she ‘should have made sure’ the assessment was updated.

But when asked if Mr Hack may have been suitable for a low-profile bed, which was fitted with crash mats to reduce the impact of potential falls, she maintained he may not have been eligible.

She also explained the ward had two observational bed spaces, where patients could be kept under closer watch but they were occupied at the time.

Instead, hourly checks were made on Mr Hack.

Since the incident, the hospital has tightened up documentation and handover procedures, patients are given special gripping socks and new equipment, including pressure sensor mats, had been purchased.

The number of falls was adjudged to be on the decrease.

In recording a verdict of accidental death, coroner Dr David Skipp said the measures taken were ‘excellent’ .

He acknowledged the risk of falls, particularly in the case of geriatric wards, would never be completely eliminated.

Mr Hack died primarily of an acute subdural haemorrhage as a result of the fall.

The Herald requested a comment from Western Sussex Hospitals NHS Trust but they were unavailable for comment.