Man who died after fall had care plan cut in error

Victor Hutchens died after an accidental fall at Darlington Memorial Hospital

A man who died after an accidental hospital fall had his care visits reduced in error in the days before his death, a coroner has said.

Victor Hutchens, who was a patient at Darlington Memorial Hospital, died on 27 February.

The 85-year-old had his care rounds reduced from hourly to four-hourly in the week before his death, a prevention of future deaths report said.

Rebecca Sutton, assistant coroner for County Durham and Darlington, has sent a formal warning to the trust which runs the hospital over concern the error could occur again. A spokesperson said it had "fully investigated" the circumstances around the death and "strengthened procedures".

Mr Hutchens died due to a head injury caused by an accidental fall at the hospital, an inquest found.

On 20 February, seven days before his death, a member of staff mistakenly downgraded his care visits to every four hours, but Ms Sutton said they were unaware of how the error occurred.

"It cannot be said, on a balance of probabilities, that the error contributed to the deceased's death," her report said.

However, she admitted there was a "concern that the error could occur again and could cause or contribute to a future death".

The report, sent to the trust's chief executive, must have a legal response from the trust by 2 October.

A spokesperson for County Durham and Darlington NHS Foundation Trust said: "We would like to express our sincere condolences to the family of Victor Hutchens.

"We have fully investigated the circumstances of his death and strengthened procedures to ensure care round frequencies are recorded accurately and monitored in real time via handheld devices and electronic patient records."

The trust added that initiatives put in place over the past two years have contributed to reductions in the number of falls in its hospitals and are being extended elsewhere.

"Our falls committee continues to review trends, share best practice and drive improvements, reflecting our ongoing commitment to patient safety and the prevention of future harm," the spokesperson added.