Trust apology after grandad’s death
AFRAIL grandad had his walking stick taken off him because he was waving it aggressively in hospital – before having a bad fall, the consequences of which contributed to his death, an inquest jury has concluded.
George Thornsby, 81, from Rochdale, died of a lung infection following surgery to repair a broken hip after taking a tumble on a ward.
Despite initially being admitted to hospital weeks before following an earlier slip – and having a history of falls – medics did not properly assess or manage the risk of him getting hurt again, a jury said.
A ‘fall care plan’ was put together around a month after Mr Thornsby was admitted to hospital, but it was not sufficiently communicated between medics, the inquest heard.
Jurors concluded that Mr Thornsby died as the result of an ‘accident with neglect’.
There were found to have been a series of failures in his care and ‘missed opportunities’ to prevent further falls.
Bosses at Pennine Care NHS Foundation Trust admitted the care provided was not acceptable and said an improvement plan has been drawn up and put into action.
Rochdale Coroners’ Court earlier heard Mr Thornsby was first admitted to Rochdale Infirmary on April 18 after he had a fall.
Mr Thornsby, who left behind three children, six grandchildren and wife of 57 years Barbara, 78, suffered from vascular dementia. He was detained under the Mental Health Act following his admission.
He was seen being ‘aggressive’ and, after waving it at people, had his walking stick taken off him.
Mr Thornsby, a retired painter and decorator, was transferred to Royal Oldham on May 2 and put on the Rowan ward – a specialist mental health unit for older patients.
The court heard that on May 22, he was transferred to Beech ward. The jury found that process ‘appeared rushed, did not follow normal procedures’ – and that ‘no interward communication was evident’.
“This transfer was not in Mr Thornsby’s best interests,” jurors said in their written conclusion.
The inquest heard information transfer between wards was poor, meaning the risk of Mr Thornsby falling was not communicated.
Just six hours after moving to Beech ward, Mr Thornsby took a tumble and broke his hip.
Mr Thornsby fell at least three other times following his admission, jurors were told.
He died of bronchopneumonia following surgery to repair a femur fracture. The final fall was found to have been a contributing factor in his death.
Following the two-day inquest, coroner Peter Sigee said: “I have been concerned during the course of the hearing as to the circumstances surrounding Mr Thornsby’s transfer from the Rowan ward to the Beech ward and the way in which the known risk of falls was managed. Shining a light on what happened to Mr Thornsby is what is needed to make sure this sorry series of events does not happen again in the future.
“He did not receive the care and treatment that he should have done.”
Mr Thornsby’s son George, who represented his family at the inquest, said: “We were quite clear in our own minds that there were failings.
“The inquest was about getting those findings recognised and from the evidence we were presented with, it confirmed the fears we had when my father was still alive. He loved his family, who have fond memories of time spent on holidays together, playing games and just having a simple family life.
“We would not want our family’s experiences to ever be repeated.”
Dr Henry Ticehurst, medical director for Pennine Care NHS Foundation Trust, said: “We would like to offer our most sincere condolences to George’s family and friends.
“We fully accept that the care we provided to George fell below the high standards we set ourselves and are deeply sorry for this. We carried out our own detailed investigation immediately following his death.
“We have already strengthened our processes for handing over a patient’s care to another team. This includes ensuring a fully qualified member of staff undertakes the handover on every occasion and that key information about a patient’s care needs is provided.
“These improvements will be shared across all of our mental health services.”