Assistant coroner warns hospital trust that it must take urgent action to prevent future deaths of patients under its care

The warning from Rachel Galloway comes in the wake of the death of pensioner Patrick Clifford, who died in the aftermath of an unsupervised fall he suffered while he was a patient at Royal Blackburn Hospital.

While Ms Galloway said she believed Mr Clifford’s time under the care of the trust did not contribute to his death on the balance of probabilities, she did warn that there were opportunities missed.

In a report sent to the trust, Ms Galloway raised concerns about nursing staff’s understanding of policy when it comes to falls, difficulties in transferring X-ray images to other hospitals and the radiology department at the Royal Blackburn Hospital refusal to carry out a specific type of X-ray which Mr Clifford needed.

Responding to the report, Dr Damian Riley, executive medical director at the trust, said an investigation had been carried out in the wake of Clifford’s death and its processes had been updated.

In the report, Ms Galloway, who is the assistant coroner for Blackburn, Hyndburn and the Ribble Valley, stated how Mr Clifford fractured his hip after fainting in the toilets on ward B4 at the Royal Blackburn Hospital on March 19,2016.

Over time the 88-year-old developed pneumonia due to immobility and heart failure and died at Springhill Care Come in Accrington on September 18, 2016.

But Ms Galloway said it was his care in the intervening period which had raised concerns.

She wrote: “Mr Clifford suffered a fall in the toilet at Royal Blackburn Hospital where he was a patient on March 19, 2016. No risk assessment had been carried out but I found that the fall would not have been prevented had a risk assessment taken place, as there was no requirement for Mr Clifford to be supervised in the toilet due to his level of his mobility.

“The trust accepted that a risk assessment should have been carried out and this has now been addressed on Ward B4. During the course of the evidence, it appeared to be suggested that supervision in the toilet would not be required unless there had been a fall on the ward (even if there had been a relevant fall at the patient’s home or other risk factors were present).

“Following the fall, Mr Clifford sustained a fractured (acetabulum) hip. This was treated conservatively, as surgery was not recommended. He was referred to orthopaedics at Royal Blackburn Hospital and then referred to Wrightington Hospital for advice to be obtained on the fracture. The referral to Wrightington was mainly to obtain advice on the fracture and to obtain their expert opinion on when weight bearing or partial weight bearing could commence.

“There were delays in obtaining advice from Wrightington, which led to extended bed-rest in Mr Clifford’s case. These delays were due to problems with accessing the images from different PACS systems at the hospitals and misunderstandings as to whether Wrightington could access the images. There were also delays caused by the radiology department at the Royal Blackburn Hospital refusing to undertake the Judet (X-ray of pelvis) views that were specifically requested by Wrightington.

“Whilst there were delays in commencing partial weight bearing and communications issues later at Burnley General Hospital regarding daily hoisting,

“I concluded that these matters did not contribute to Mr Clifford’s death in September 2016 on the balance of probabilities. However, these were missed opportunities to improve his condition.”

Ms Galloway added: “In my opinion action should be taken to prevent future deaths and I believe you have the

power to take such action. “

Dr Riley said: “Our thoughts are with the family and friends of Mr.Clifford and we appreciate this is a very difficult time for them.

“Following Mr Clifford’s death, an investigation was carried out and the findings shared with the Coroner, the family and the clinical staff involved in Mr. Clifford’s care.

“The Coroner has received assurance that Trust processes were updated and recommendations identified during the investigation have been implemented.”