A coroner has informed a north London NHS trust that it exhibited “significant communication problems” following the death of an elderly patient who fell without witnesses at a hospital.
Carl Eastman, aged 96, suffered a fatal brain hemorrhage after an incident in the enhanced care bay at the Royal Free Hospital in Camden on July 28 of the previous year.
During an inquest into his demise at the Inner North London Coroner’s Court, it was revealed that Mr. Eastman had been admitted to the facility five days prior after experiencing a fall at home, yet he had fallen again within the hospital ward on both July 25 and July 28.
Officials from the Royal Free London NHS Foundation Trust have been approached for their comments on the matter.
Mr. Eastman was moved to the hospital’s enhanced care bay, “where it was expected he would be under continuous observation,” noted assistant coroner Ian Potter in a report addressing the prevention of future fatalities.
The third fall, which witnesses did not see, happened in the early hours of July 28, “at a time when staff should have been providing accompaniment,” the coroner remarked.
Mr. Potter indicated that there was “evidence of what I perceive as ‘significant communication issues’ in Mr. Eastman’s care,” which raised concerns that “future fatalities could arise unless corrective measures are implemented.”
He highlighted that, on July 28, ward staff mistakenly informed the on-call physician that there had been no falls, leading to a failure to reassess Mr. Eastman’s condition.
The communication between the ward personnel and medical team was described as “poor,” and the information presented during the inquest showed “shortcomings in fundamental record-keeping,” the coroner stated.
Mr. Potter commented: “There is clear evidence that the trust has implemented extensive measures to tackle the failure of staff to adhere to the trust’s own post-fall protocols and guidelines.
“Nonetheless, I am worried that the issue may extend beyond these specific protocols and could reflect a broader deficiency in skills or knowledge.”
Additionally, the evidence suggested “a lack of professional curiosity from certain staff members,” he added.
Copies of the coroner’s Prevention of Future Deaths Report have been distributed to the chief executive of the Royal Free London NHS Foundation Trust, Mr. Eastman’s family, and the Care Quality Commission.
