A claim has been settled by Penningtons Manches’ clinical negligence team against Maidstone and Tunbridge Wells NHS Trust regarding Sheila Acott, a 67 year old woman who died following a fatal fall in Maidstone Hospital in February 2013.
Sheila was an inpatient at the hospital with multiple medical problems which limited her mobility to walking with a zimmer frame, usually with the assistance of another person for transfers. Various factors made her at high risk of falling, including a history of vertigo.
In the early hours of the morning on 13 February 2013, Sheila had a fall and sustained a massive blow to her head. Witness evidence from the nurses present suggested she was wandering unaided and without her zimmer frame in an agitated state. She was then seen standing on her own without any mobility aid or nursing assistance for support. The account is that Sheila suddenly fell backwards and landed “on her head”.
She was found to have a major laceration to the back of her head and was bleeding profusely. A doctor was called to examine her and to suture the wound. She was then taken back to bed and the family were informed of the fall several hours later. A decision was made not to CT scan Sheila’s head on the basis that her Glasgow Coma Scale (GCS) score was a very normal 14/15.
The nursing witness evidence suggests that the nurses asked doctors on several occasions whether a CT head scan should be ordered given the circumstances of the fall, specifically that she fell from her own height directly onto her head. A CT scan was not felt to be clinically indicated. Instead, Sheila was to have regular neurological observations, but these appeared to cease approximately 15 hours after the fall.
On the morning of 14 February Sheila suffered a drastic drop in her GCS level from 14/15 to 5/15 and began bleeding from her mouth and nose. The hospital then performed an urgent brain CT scan more than 36 hours after the fall. The scan showed a massive haemorrhage caused by the fall and the neurosurgeons advised that nothing could now be done for her. Sheila died that evening and the post mortem report confirmed the cause of death as head injury.
Mrs Acott’s family instructed Lucie Prothero, associate in the Penningtons Manches clinical negligence team who specialises in hospital falls cases to make a claim against Maidstone and Tunbridge Wells NHS Trust.
Due to the unexpected nature of Sheila’s death, the coroner opened an inquest in February 2013 and investigations began. Having heard all the evidence, the coroner recorded a verdict of accidental death. She found that Sheila was at high risk of falls but that a falls risk assessment, manual handling assessment and falls care plan had been either partially completed or not at all. During the 16 days that Sheila was an in-patient before her fall, the paperwork was never reviewed by either the ward manager or any of the nursing staff. The coroner found that, if the nurses had known of Sheila’s high risk of falls, they would not have left her unassisted at the nurses’ station and the fall could have been avoided.
The case received widespread media coverage following the coroner’s verdict. BBC South East ran the story in both the evening news bulletins on Tuesday 15 April, including pre-recorded interviews with Lucie and Sheila’s daughter, Nicola Davies. Lucie was also interviewed for BBC Radio Kent and briefed the Kent Messenger which ran the story both online and in the weekly paper.
The claim was submitted to the trust and, although no formal admission of negligence was made, the case subsequently concluded when the NHS Litigation Authority accepted an offer to settle made by Mr Acott.
Commenting on the settlement, Lucie Prothero said: “We are pleased to have reached an amicable and swift settlement of Mr Acott’s claim, after what has been a very distressing time for him and his family. We are seeing increasing numbers of clinical negligence cases relating to hospital falls, where simple failures to provide a safe environment for patients can result in avoidable falls which can have devastating consequences. Mrs Acott’s case provides another example where a vulnerable patient has fallen, yet basic safeguards and adequate nursing care would have avoided it.”