Norfolk Coroner raises concerns over woman's fatal fall

Irene Fitches, 77, was seen at the Norfolk and Norwich University Hospital in July 2021

A coroner has raised concerns about a hospital's policies after a patient suffered a fatal fall.

Irene Fitches, 77, went to Norfolk and Norwich University Hospital (NNUH) on 17 July because she felt dizzy.

Deemed well enough to be discharged she injured her head in a fall in her room on 21 July and died the next day.

Norfolk coroner Jacqueline Lake said the hospital's falls policy did not meet NICE guidelines. The hospital said it would be liaising with the coroner.

An inquest into Mrs Fitches' death, which concluded on 11 February, heard she had a "significant" past medical history.

On 17 July, she was admitted to hospital and diagnosed with benign positional paroxysmal vertigo, a condition which causes problems with balance.

The inquest heard she was given a management plan and deemed medically fit for discharge.

However, the coroner said Mrs Fitches had "an unwitnessed fall in her room and suffered a head injury".

Her medical cause of death was subdural haematoma (a head bleed), a fall, and benign positional paroxysmal vertigo.

Mrs Lake concluded the death was an accident.

'Improve care'

In her prevention of future deaths report, Mrs Lake states evidence was heard that a falls policy was drafted and a risk assessment trialled at the beginning of 2020, but the Covid-19 pandemic intervened and delayed its completion.

She said it was a further concern that the hospital had no member of staff leading on falls or a staff training package on falls developed.

The report also says that assisted technology, which could alert staff to patients' needs, had not been progressed since October and was still at an early stage.

The hospital has a duty to respond, setting out action taken, or to be taken, by 14 April 2022.

Prof Nancy Fontaine, the chief nurse at NNUH, said: "Our deepest condolences are with the family of Mrs Fitches following their loss and we will be liaising with the coroner over the learning from this case.

"All recommendations will be incorporated into our clinical governance and learning processes to enable us to improve care for patients in the future."

She said a new updated falls risk assessment and accompanying policy is scheduled to be completed in March and that funding for a new Falls Improvement Lead post had been received.

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