Man, 83, died after care home fall, inquest hears

‘Despite precautions to keep vulnerable people safe, accidents still happen’

AN elderly man died following a fall at Hungerford Care Home, an inquest was told.

The facility’s care and safeguarding protocols were examined as a consequence.

But assistant Berkshire coroner Alison McCormick said at the conclusion of the inquest into the death of Terry Norman Johnson, at Reading Town Hall on Monday, October 11: “It shows very clearly that, even when organisations looking after such frail and vulnerable people take precautions to keep them safe, it’s still the case that accidents happen.”

The hearing was told that Mr Johnson, an 83-year-old, retired taxi driver, suffered a fall around 7am on Monday, February 22.

All had been well when staff had checked him just minutes beforehand – part of an hourly routine, the home manager at the time, Elizabeth Darley, told the inquest.

A sensor mat that had been installed in his room alerted staff to the fact he had got out of a specially lowered bed, and fallen.

Ms Darley told the hearing: “Terry had been assessed as at high risk from falls.”

An ambulance was called and Mr Johnson was taken to the Great Western Hospital, Swindon, after paramedics became concerned about his condition and a scan later confirmed a bleed on the brain had occurred.

Mr Johnson went on to suffer a further fall at the hospital, despite one-to-one care, after a nurse became momentarily distracted by another patient, the hearing was told.

Tests showed an ongoing bleed and Mr Johnson’s blood-thinning medication, prescribed due to a heart condition, was reversed by an injection of Vitamin K, hospital staff reported.

However Mr Johnson’s condition continued to deteriorate and neurological experts at the John Radcliffe Hospital, Oxford, who had been consulted for advice, ruled out surgical intervention.

Mr Johnson was consequently discharged back to the care home in Wantage Road, Hungerford Newtown, for more conservative care closer to his family.

He died days later, on Wednesday, March 17.

Summing up the evidence, Ms McCormick agreed with the conclusion of GP Dr Ellora Evans of Hungerford Surgery, which gave the cause of death as acute subdural haemorrhage.

Ms Darley said the care home’s safety protocols had undergone a formal review to see if lessons could be learned, but added: “No care or delivery issues were found that could have contributed to the death.”

Recording a conclusion of accidental death, Ms McCormick said: “Mr Johnson died at Hungerford Care Home following a traumatic head injury sustained in an unwitnessed fall.

“He suffered a later, witnessed fall at the Great Western Hospital... against a background of anti coagulant medication for atrial fibrilliation.

“People as frail and vulnerable as Terry was can have injuries that, in themselves aren’t serious, but can still have a fatal outcome.”

People as frail and vulnerable as Terry was can have injuries that, in themselves aren’t serious, but can still have a fatal outcome