Woman's fatal fall in Essex hospital avoidable coroner rules

Doris Smith (middle) died after a fall on a hospital ward which the coroner says could have been avoided

A fatal fall may have been avoided had a mental health trust completed a risk assessment, a coroner has ruled.

Doris Smith, 74, who had dementia, died after a fall on a mental health ward at Broomfield Hospital on 9 October 2020.

Essex Coroner Sonia Hayes raised concerns that a risk assessment that should have taken place within 24 hours of her admission took 12 days, despite other falls while on the ward.

Essex Partnership University Trust said measures have since been put in place.

Mrs Smith died five days after the fall when doctors determined she had an unsurvivable brain bleed.

The coroner said she heard evidence at the inquest that trust procedures meant a risk of falls assessment should have been completed by a nurse within 24 hours of admission.

She said the eventual assessment 12 days after her admission and observations were "inadequate".

Ms Hayes said Mrs Smith's death was a "direct result" of the fall.

"Had Mrs Smith been observed and monitored as she should have been, the fall on 9 October 2020 would either have been avoided or there would have been a staff member present to break her fall.

"Had the fall been broken, it is likely that Mrs Smith would have avoided injury, or her injuries would have been less severe," Ms Hayes said in a Prevention of Future Deaths Report (PFDR).

The coroner raised concerns Mrs Smith was not given a fall risk assessment until 12 days after she was admitted

The coroner also raised concerns about staff being confused about the the correct level of observations to be carried out on Mrs Smith, even after other falls.

The report also highlighted concerns about accurate record keeping, ineffective communication between staff

"All of these factors led to the incorrect observation of Doris Smith which contributed to the circumstances leading to her death," the coroner said.An independent review is looking at another 2,000 deaths during a 21-year period at the trust.

Paul Scott, chief executive of Essex Partnership University Trust said: "Since this very sad incident, we have put a number of measures in place to significantly reduce the risk of people experiencing falls on our wards and monitor the safety of patients who have experienced a fall or are at increased risk of doing so.

"We are committed to providing the best patient care and ensuring any learning is embedded across our organisation to help us drive forward improvement. We will respond to the Coroner in due course."