A nurse quit her job after hospital bosses gave her a final warning for not carrying out a proper neurological check on an elderly patient who fell out of bed and banged her head.
An inquest in Bradford yesterday heard Mary Tweddle Stewart, 87, who was being treated in Airedale General Hospital’s elderly care ward, later died from a massive bleed in her brain.
When the staff nurse on duty, who was not named but has since been referred to the Council for Nursing and Midwifery, bleeped for a doctor after the incident she failed to mention it was a head injury or that the patient was on blood thinning therapy.
Because of that, the message was only coded green which gave a doctor two hours to respond. If the head injury had been mentioned it would have made it a code red warranting a ward response within 30 minutes.
Mrs Tweddle Stewart was not given a neurological check until two hours after the fall by which time she was becoming unresponsive.
Before her fall she had been transferred from the stroke ward to ward one – but without a walking frame and she had been seen pushing a table in front of her to get about. She had been assessed at medium risk of falls and, because staff were worried she might try to climb over bed sides if the rails were put up, they were left down.
She also had a habit of going to the toilet at 4.30am – the time she was discovered lying on the floor near her bed. She told staff she had hit her head.
Changes to fall risk checks now mean she would have been classed as high-risk of falling, Assistant Bradford coroner Dr Dominic Bell was told by Dr John O’Dowd, the interim deputy medical director, at Airedale NHS Trust.
Dr O’Dowd said there were also moves to include patients’ toilet habit patterns in their care plans to help prevent any untoward incidents. It was already done with dementia patients.
All nurses have also been reminded about the need to carry out nerurological checks straight away if patients fall.
Once a doctor had seen Mrs Tweddle Stewart he suspected a serious head injury and an urgent CT scan showed up the bleed which was inoperable. The pensioner, from Barnoldswick, near Skipton, died on December 1 last year.
Dr O’Dowd told the hearing: “The Trust takes its fall prevention strategy extremely seriously and is trying hard to improve.”
Recording a narrative verdict, Dr Bell said he was satisfied the ward had been appropriately staffed and there had been no deviations from the falls risk assessment at the time although the ward transfer process had been in need of refinement. He added: “I’m satisfied the trust undertook a robust investigation into this and considered the need for disciplinary measures were necessary. Other remedial measures have also been introduced.”
Those measures include nurses sitting along the sides of wards at night rather than at the nurse’s station so they can hear if people need to get out of bed easier.