Coroner concerned after patient dies following fall

Suffolk Coroner Darren Stewart raised concerns to an NHS trust following a patient's death

A coroner has raised concerns about a hospital's risk assessment procedure after a man died following a fall.

Michael Burke died after falling at Ipswich Hospital and fracturing the top of his femur on 2 February 2023.

Suffolk Coroner, Darren Stewart, concluded the fall made a "material contribution" to Mr Burke's death and said he was concerned the hospital had "inadequate arrangements" when dealing with risk assessments.

Nick Hulme, chief executive of East Suffolk and North Essex NHS Foundation Trust, said "significant changes" had been made since the incident.

In a prevention of future deaths report, Mr Stewart detailed that Mr Burke had been suffering with chronic obstructive pulmonary disease since 2008.

On 26 January 2023, staff at the care home where he lived found him collapsed in the toilet with "dangerously low" oxygen saturation levels.

He was taken to hospital and found to be suffering from a chest infection and delirium "caused by both his infection and the effect of the pain medication" he was taking, the report said.

Four days later he fell in the hospital ward while attempting to get out of bed, and he died several days afterwards.

Mr Burke was being treated at Ipswich Hospital when he fell and fractured a femur

During Mr Burke's inquest, the court heard that risk assessments were to be carried out regularly on patients "in relation to their fall risk".

Mr Burke was found to be a risk, and arrangements were required to manage this following his fall at the care home.

According to Mr Stewart's report however, Mr Burke was not risk assessed when transferred to a new ward in Ipswich Hospital.

"The outstanding task to carry out the risk assessment had not been completed by the end of the shift during which he had been transferred onto the ward," he said.

"This requirement was not handed over to the on-coming shift and a falls risk assessment had not been completed at the time Mr Burke sustained a fall on the ward."

Mr Stewart said he was concerned the hospital had inadequate arrangements to "highlight circumstances where the requirement for risk assessments have not been completed", including during the handover of tasks between shifts.

Mr Hulme said the trust was "committed to reducing the number of falls... as well as the harm from falls that occur".

He said changes made included completing falls risk assessments on admission and transfer to a ward, as well as updating policies and procedures regarding falls prevention.

"All the findings from the coroner have been shared to make sure further learning continues across the Trust," he added.