NHS trust warned of âwidespread communication issuesâ after man died from fall
Carl Eastman, 96, suffered an irreversible bleed on the brain after falling in the Enhanced Care Bay of the Royal Free Hospital in north London.
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A coroner has told an NHS trust it displayed âwidespread communication issuesâ after an elderly patient died from an unwitnessed fall at one of its hospitals.
Carl Eastman, 96, suffered an irreversible bleed on the brain after falling in the Enhanced Care Bay of the Royal Free Hospital in Camden, north London, on July 28 last year.
An inquest into his death heard Mr Eastman had been admitted to the hospital five days earlier following a fall at home and that he fell again while in a hospital ward on July 25, although neither incident resulted in significant injury.
He was then transferred to the Enhanced Care Bay âwhere he should have been kept under constant observationâ, said Ian Potter, assistant coroner for inner north London, and his third unwitnessed fall in the early hours of July 28 occurred âat a time when a member of staff should have accompanied himâ.
The hospital is run by the Royal Free London NHS Foundation Trust, along with three other hospitals in London and Hertfordshire.
The coroner said there was âevidence of what I considered to be âwidespread communication issuesâ in the care provided to Mr Eastmanâ, including staff on the ward incorrectly telling the on-call doctor on July 28 that nobody had fallen, meaning Mr Eastman was not reviewed.
Communication between the ward staff and medical staff was ânot goodâ and evidence provided at the inquest revealed there were âdeficiencies in basic record keepingâ, the coroner said.
He said evidence appeared to show âa lack of professional curiosity on the part of some staff membersâ and the possibility of an underlying skills or knowledge deficit at the hospital.
The coroner added: âIn my opinion action should be taken to prevent future deaths.â
Copies of the coronerâs Prevention of Future Deaths Report were sent to the chief executive of the Royal Free London NHS Foundation Trust, Mr Eastmanâs family and the Care Quality Commission.
A statement from the Royal Free London NHS Foundation Trust said: âWe would like to apologise that Mr Eastman died while under our care and to send our deepest condolences to his family.
âWe take the coronerâs findings extremely seriously and will respond to all the matters he has raised as soon as possible.â
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