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Nurse quit after fatal fall checks warning
10:00am Friday 2nd May 2014 in News
A staff 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 heard on Monday how Mary Tweddle Stewart, 87, who was being treated on Airedale General Hospital’s elderly care ward, had 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.
Mrs Tweddle Stewart, who lived in Barnoldswick, was not given a neurological check until two hours after the fall, by which time she was becoming unresponsive.
An urgent CT scan showed up the bleed, which was inoperable, and the pensioner died on December 1 last year.
The inquest heard that before her fall, Mrs Tweddle Stewart had been transferred from the stroke ward to ward one, but without a walking frame. 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.
Since the incident, changes had been made to fall-risk checks and nurses had been reminded about the need to carry out neurological checks straight away if patients fell.
Dr John O’Dowd, the interim deputy medical director at Airedale NHS Trust, told the hearing: “The trust takes its fall prevention strategy extremely seriously and is trying hard to improve.”
Recording a narrative verdict, assistant Bradford coroner Dr Dominic Bell said he was satisfied the ward had been appropriately staffed.
He said there had been no deviations from the falls risk assessment at the time, although the ward transfer process had been in need of refinement.
Dr Bell 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 included nurses sitting down the sides of wards at night rather that at the nurse’s station so they could better hear if people needed to get out of bed, he added.
Harold Hosker, interim medical director for the trust, said: “This was a tragic death and we send our sincere sympathies to the patient’s family.
“Following Mrs Tweddle Stewart’s death, we have carried out a thorough investigation to understand why it happened and to ensure we learn all the lessons from this regrettable incident.
“Falls in hospital are one of our most important priorities and we are working hard to improve our ward environments and clinical settings for older people.
“In February, we opened our first dementia-friendly ward which includes decoration in bright colours on bays and around new toilets, shower and bathrooms to help patients find their way back to their beds and prevent disorientation along with new flooring with non-shiny material which patients perceive as less slippery.
“In addition, we have further reviewed our falls prevention policy in relation to observations that must be carried out following all head injuries and additional training has been provided to nursing staff across the trust.”