Frail patient died after climbing out of hospital bed and hitting his head - even though he should have been watched round-the-clock by medics
Short-staffing at the Clifton Hospital in St Annes made it ‘impossible’ to watch a man before he fell and died, an inquest was told.
Medics should have nursed Barrie Keith Housby, 81, on a one-to-one basis because he was prone to falling, confused, and agitated – trying to climb out of his bed.
But, at the start of the night shift, he was left alone by a worker who went to finish other tasks.
Mr Housby, a retired engineer of Mason Close, Freckleton, then got out of bed, fell, and suffered a catastrophic brain injury when he banged his head.
He died the next day, with his inquest in Blackpool ruling: “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.”
Blackpool’s coroner Alan Wilson has now written to the Government warning that, unless action is taken, more people could die needlessly.
Although he ruled Mr Housby died as a result of an accident, he said in his letter – sent to the Department of Health and Social Care and the minister responsible for patient safety, Maria Caulfield MP – hospital bosses need more support to tackle their staff shortage.
“It seems to me that Blackpool Teaching Hospitals NHS Foundation Trust [which runs the Clifton Hospital and Blackpool Victoria Hospital] 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.”
Mr Housby, who was born in the resort on September 15, 1939, and had a history of frailty, Parkinson’s Disease, and macular degeneration which affected his vision, was admitted to hospital after repeatedly falling at home.
He was moved to the Clifton Hospital on Thursday, July 1 for rehabilitation and, the inquest at the town hall was told, his condition improved.
By July 10 and 11, he was appearing to be lucid and medics were considering him for discharge.
On the night of Monday, July 12, when he should have been monitored round-the-clock, he wandered unobserved from his bed before being found by a healthcare assistant (HCA) who led him back.
At around 10.55pm, with him seemingly settled, the worker allocated to watching him went to complete a routine job she had been unable to finish earlier because of staffing levels, the court was told.
“She intended to return a short time later,” Mr Wilson said.
“Before she could do so, Barrie left his bed and was heard to fall to the floor.
“Staff entered the bay and went to his aid, but he was found unresponsive.”
Mr Housby was taken by ambulance to A&E at the Vic, with a scan revealing the extent of his injuries.
He died at 10.45am.
His inquest was told that, before the start of the night shift, bosses decided to “reduce the number of staff working that shift due to unexpected staff absences”, with medics redistributed to other areas.
“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 she had been so busy during the shift up to that point as a direct result of the staff shortage,” Mr Wilson said.
One HCA told the inquest it was “impossible” to provide one-to-one care to Mr Housby with the number of staff on duty that night.
A clinical matron told the court policy changes had been made since Mr Housby’s death – though staffing challenges remained.
And Mr Wilson said that, as long as they do, patients at the rehab hospital “are being put at risk”.
Pete Murphy, director of nursing, allied health professionals and quality at Blackpool Teaching Hospitals NHS Foundation Trust, said: “Mr Housby’s death was a tragic incident and we would like to extend our condolences to his family at such a difficult time and offer our sincere apologies.
“The inquest found that Mr Housby’s death was accidental, but raised a number of factors which were considered to have played a part in his death.
“We fully accept the coroner’s findings and would like to offer reassurances that we have worked hard to introduce changes which will help ensure another family doesn’t suffer in the same way.
"These have included a new policy regarding falls, and we will continue to learn from these lessons right across the trust."
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