A pensioner died after suffering five falls in five days in hospital.
After Tom Gower’s fifth fall he was put back into his bed by staff who failed to notice he had suffered a fractured hip and shoulder.
It was not until morning rounds, five hours later, that the injuries were found and he was sent to X-ray.
Mr Gower, 97, from Patcham, Brighton, died ten days later from pneumonia, partly caused by immobility due to his injuries.
At an inquest in Brighton, coroner Veronica Hamilton-Deeley described the incident as “disgraceful”.
She also criticised the Royal Sussex County Hospital in Brighton for delaying his hip operation for 60 hours when the procedure is normally carried out within 24 hours for the best chance of recovery.
Seizure
Mr Gower’s grieving family said they hoped the inquest would mean no other family would have to go through what they did.
Mr Gower had been admitted to Vallence ward on January 6 after suffering a seizure at home.
The inquest was told he was confused and would wander round the ward but there was no evidence of any careful assessments of his falls.
The ward was full and closed to new patients due to a norovirus outbreak.
Staff were under pressure and Mrs Hamilton-Deeley said it was not possible for them to adequately attend to Mr Gower’s needs.
Retired electrician Mr Gower suffered his last fall at about 5am on January 15. Staff put him back into bed and hospital notes recorded how he was checked for possible injuries but there were “nil found”.
The inquest was told staff called for a doctor and a clinical site manager but neither attended and his injuries were not spotted until 10.10am.
X-rays were ordered but were not seen by the orthopaedic team until 6pm and his hip was not operated on until two days later, 60 hours after the fracture had occurred.
Mrs Hamilton-Deeley said: “I find it disgraceful he was left for up to five hours before the possibility of serious injuries was recognised.”
It was also “unacceptable” he had to wait two-and-a-half days before his hip was operated on. Mrs Hamilton- Deeley gave a narrative verdict criticising the hospital, saying there was no evidence that measures were taken to prevent Mr Gower’s falls and neither was there evidence nursing staff had carefully examined him after his last and most serious collapse.
Brighton and Sussex University Hospitals NHS Trust apologised.
Chief executive Duncan Selbie said: “My deepest sympathies are with Mr Gower’s family at what I appreciate is an extremely sad and difficult time.
“As with other vulnerable patients on the ward, Mr Gower was in a bed near to the nurses’ station so he could be monitored more closely than others.
“Mr Gower repeatedly got up and moved about at night, even though he was unsteady on his feet, and this did make him prone to falling. The nurses on the ward were aware of this and did their best in the circumstances to maintain his safety.”
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