Man banged his head and died on Clifton Hospital ward where staff were told to watch him

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“Had a member of staff remained on the bay with Barrie at all times he would probably not have been able to leave his bed and suffer a fall.”

 

Clifton Hospital
Clifton Hospital

A man who died in hospital after suffering a head injury could have lived if more staff were available to watch him, a coroner has found.

Barrie Keith Housby died in Clifton Hospital in July after falling to the floor, despite instructions that he must be watched by a member of staff at all times.

An inquest into the death of Mr Housby has resulted in senior coroner, Alan Wilson, issuing a report calling for change in order to prevent further instances of this kind.

Mr Housby’s medical history included frailty, Parkinson’s disease and macular degeneration as well as this, he was known to be prone to falling.

On July 1, Mr Housby was taken to the hospital for rehabilitation and during this time, he was known to be confused and agitated and known to make attempts to climb out of his hospital bed meaning he required one to one observation by a member of staff.

Over a week later, around July 10 and 11, he was improving and was even being considered for discharge from the hospital.

During a night shift on July 12, staff were reminded that he was to be nursed on a one to one basis and that they should not leave his bay unattended.

Shortly afterwards, Mr Housby wandered unobserved from his bed and had to be returned to his bed by health care assistants (HCA’s).

Just before 11pm, a member of staff allocated to monitor him thought Mr Housby was settled in bed and left his bay to attend to other duties that she had not completed earlier in the day, in part due to a shortage of staff.

Within this time, he left his bed and was heard to fall to the floor. Despite staff coming to his aid, he was found unresponsive.

A CT scan revealed he had received a catastrophic brain injury and Mr Housby died at 10.45am the next morning. The medical cause of Mr. Housby’s death was a traumatic subdural haemorrhage following a fall.

Senior Coroner for Blackpool & Fylde, Alan Anthony Wilson stated in the report: “Had a member of staff remained on the bay with Barrie at all times he would probably not have been able to leave his bed and suffer a fall.

“Staffing levels did contribute to this incident. The HCA’s decision to leave the bay was affected by the reduction in staff because she felt there were duties she ought by that point in the shift have completed but these remained outstanding because there had because she had been so busy during the shift up to that point as a direct result of the staff shortage.”

During the inquest hospital staff explained to the court that the reduction in staff numbers meant that they did not have enough time to carry out their expected tasks.

As one HCA told the court, it was “impossible” to provide one to one nursing care to Mr Housby with the number of staff working that shift at that time.

The court was told that since Mr Housby’s death, the problem of staffing shortages persists.

Following this, Mr Wilson laid out his concern’s for the hospital in the report which he has addressed to the Secrtary of State and the Department for Health and Social Care.

The concern’s in the report conclude: “Clifton hospital is a place to where patients – often elderly and vulnerable – are transferred for a period of rehabilitation, usually from an acute hospital setting.

“The aim usually is that following such rehabilitation they can hopefully return to their homes, or perhaps be discharged to a suitable care home. However, these patients are being put at risk due to a shortage of staff.”

The report continued on to add: “It seems to me that Blackpool Teaching Hospital NHS Foundation Trust is very much aware of the issue, and are trying to resolve it and that the ongoing efforts to recruit is very much part of this.

“However, the risk to patients persists, and I feel it would be remiss of me not to write this letter in order to further highlight the problem. Blackpool is an area that can face difficulties attracting and retaining staff.

“It seems to me that the hospital Trust needs more support as they try to remedy this problem.

“When a Coroner writes a report such as this one, it is not for the Coroner to be prescriptive about what ought to be done about the issue, but to raise the concern with the relevant individual and / or organisation who may be able to address this.”

Addressing the Department of Health and Social Care Mr Wilson added: “In my opinion action should be taken to prevent future deaths and I believe you have the power to take such action.”

A Department of Health and Social Care spokesperson said: “Our condolences go out to the family and friends of Barrie Keith Housby. We are committed to ensuring the NHS provides safe, high quality care.

“We will carefully consider the concerns raised and will respond directly to the coroner in due course.”

Blackpool Teaching Hospitals Trust has been contacted for comment.