Coroner's concern over number of falls at Hull hospitals

Bryan Fulstow, 83, died from a bleed to the brain following a fall on a ward at Hull Royal Infirmary in November 2022

A coroner has written to health watchdogs about the number of falls at East Yorkshire hospitals after a patient died of a head injury.

Area Coroner Lorraine Harris raised her concerns at the inquest into the death on a ward at Hull Royal Infirmary.

Bryan Fulstow, 83, died from a bleed to the brain after he fell getting out of bed in November 2022.

The coroner ruled that his death was accidental, but raised concerns about the hospital's policy to prevent falls.

She said she had written to the Care Quality Commission and the Integrated Care Board after she "started to notice a number of falls".

The inquest heard Mr Fulstow, who had mobility problems, was taken to the Accident and Emergency unit on 10 November 2022 after becoming confused.

He had to wait several hours in an ambulance outside before he was admitted and diagnosed as having possible sepsis infection.

He was transferred to a ward where he had to wait in a chair for 11 hours until a bed became available.

He spent five days on the ward and his infection was being successfully treated and he was expected to make a full recovery.

However, Mr Fulstow was found on the floor of the cubicle on the morning of 15 November by nursing staff who responded to his calls for help.

A CT scan showed acute bleeding on the brain and his family was told it was not survivable. He died later the same day.

His son Steven Fulstow told the inquest the family felt the NHS "had failed him" and he "should still be with us".

Steven Fulstow said the family felt the NHS "had failed" their father

The family raised concerns about why their father was kept in a separate cubicle on the ward.

"We do strongly believe he wasn't in the most visible place on the ward and if he had been in a bay with other patients he would have been more visible to staff," Mr Fulstow said after the hearing.

Giving evidence, Victoria Sharman Nurse Director at Hull University Teaching Hospitals NHS Trust said medical staff thought that due to his confusion it was better to keep Mr Fulstow in a room on his own.

She added the cubicle was considered suitable for patients at risk of a fall, due to the number of passing nursing staff.

She said Mr Fulstow "showed no signs of trying to get out of bed unaided".

Ms Sharman said the hospital trust had expanded its "falls team" and new face-to-face training on reducing the risk was being given to staff which she described as a "significant priority".

She also apologised to the family for "poor communication" about their father's treatment.

The hospital trust expressed its "sincere condolences to his family and loved ones for their loss."

"We would like to apologise for the care received by Mr Fulstow at Hull Royal Infirmary last year, which we accept did not meet the expectations of his family, or the high standards we expect," a trust spokesperson said.

"We have investigated all of the circumstances relating to Mr Fulstow's care and we acknowledge the findings of the coroner. Since this incident we have prioritised staff training on patient falls and we are in the process of expanding our Falls Team at the Trust to reduce the risk of a similar occurrence in the future."