• Five patients die in four months in the same part of hospital
  • Coroner criticises East Kent trust
  • Risk assessments “inadequate, incomplete, not reviewed or not enforced”

An acute trust has been heavily criticised by a coroner after five patients died following falls in the same frailty unit within four months. 

All five of the patients were on the Cambridge floor at the William Harvey Hospital in Ashford, run by East Kent Hospitals University Foundation Trust. Three of the deaths – which occurred between January and April 2017 – led to the Central and South East Kent coroner issuing prevention of future deaths reports.

In two of the reports, coroner Patricia Harding said: “Common to each [of the deaths] was the fact that the death was caused as a result of a fall on the ward in circumstances where falls risk assessments were either inadequate, incomplete, not reviewed or not enforced.”

Three of the inquests were completed in the autumn of last year when she said the trust had been given an opportunity following earlier inquests to provide evidence of changes – but that not all of the work had been implemented at the time of the inquest hearings. Several of the patients were elderly and frail or confused at the time they were admitted to the ward.

In the case of Peter King – who died from a severe head injury apparently sustained when he climbed through the gap between his bed rails and the end of the bed – risk assessments and interventions were not properly documented and there had been no referral to the trust’s falls team or physiotherapy team. Bed rails had not been recommended and a request that he should be placed in an observable bed with a crash mat had been passed to the site coordinator but did not appear to have been acted on.

Henry Honour broke his neck of femur while on the Cambridge L ward. The coroner said his falls risk assessment and later reviews were “at best perfunctory” and he should have been placed in a bed where staff could observe him.

Harold Wonfor, 78, had not been assessed for falls during the 24 hours he was on the clinical decision unit – despite hospital policy which says this should have been done within six hours. He was then transferred to Cambridge L Ward, where no assessment was done on arrival. Within 30 minutes he had an unwitnessed fall, striking his head on a sink.

Susan Acott, the interim chief executive of East Kent Hospitals University FT, wrote to the coroner last month, confirming that the trust had made improvements. The trust’s performance in the national falls audit had shown an improvement between 2015 and 2017, and the trust policy reflected National Institute of Health and Care Excellence guidance around managing all patients over 65 as if they were at risk of falls.

Cambridge wards often had confused and wandering patients, Ms Acott said, and the trust had introduced a new method of ensuring staffing on each ward matched the demand based on the number and acuity of patients. An associate practitioner for falls prevention had also been recruited. She added that the trust had a falls rate lower than the average in the 2015 national falls audit.

Ms Acott said: “We will continue our commitment to deliver a safe and effective service to our patients.”