Inquest into death of widow who fell from hospital bed

Sitting in Ballymena on Friday, the in inquest was held into the death of 86-year-old widow Mrs Elizabeth Gilmour in the Coleraine hospital on November 12th, 2007.

The Coroner, Brian Sherrard, said the purpose of the inquest was not to examine any issues of liability or blame but was only to establish the basic and important facts regarding Mrs Gilmour’s death and “to give the Gilmour family some element of closure”.

A pathologist’s report showed that Mrs Gilmour died from a subdural haemorrhage due to a blow on the left side of the head.

First to take the witness stand was Kenny Gilmour, son of the deceased.

He told the inquest that his mother had lived in an apartment in Killowen Court in Coleraine following a spell in hospital following a transient ischemic attack (TIA) or mini stroke.

He said that Mrs Gilmour was slightly confused after the TIA and had moved into Killowen Court for peace of mind. He said that she had a fear of being on her own but was mentally the same as she was before the mini stroke.

He said that she was becoming slightly forgetful as any 86-year-old would but added that the family was never concerned about any serious mental confusion, nor were they alerted to the issue by any staff from Killowen Court.

“We visited her seven days a week, twice a day and didn’t notice any erratic behaviour,” he said.

He admitted that his mother had a few falls in isolated incidents but said they did not feel she was at risk.

The inquest was told that Mrs Gilmour was admitted to Causeway Hospital in Coleraine on October 25, 2007.

“There were many aspects of her care which were first class but there were many things we were concerned about,” said Mr Gilmour.

He said that there were bed rails around his mother’s bed which he assumed was normal procedure. He said the decision to put these rails on her bed was not discussed with her family.

The inquest heard that on November 4 Mrs Gilmour suffered a fall from her hospital bed and also later fell from a chair.

“Nothing specific happened between these two dates but over that period there was a substantial deterioration in her mind process,” he said.

Mrs Gilmour then suffered another fall her from hospital bed on November 6.

He told of being called to the hospital and seeing his mother with “horrendous bruises” on her face.

“It was very difficult to comprehend what had happened to her,” he said. Mrs Gilmour subsequently died on November 12.

Mr Gilmour was asked by his own counsel Mr Sharp if he was aware of any additional resources being brought into play in his mother’s hospital ward following the November 6 fall.

Mr Gilmour said that he noticed a member of nursing staff sitting with one patient in the ward through the night as he was deemed to be vulnerable to risk of a fall.

Also giving evidence via video link from the Royal College of Surgeons in London was neurosurgeon Mr Thomas Cadoux-Hudson DPhil.

He gave a summary of a report he had compiled based on the medical notes from Causeway Hospital.

He said Mrs Gilmour had a combination of problems including increasing confusion, unsteadiness of her feet and a tendency to fall.

He noted that Mrs Gilmour had a CT scan following a fall on October 23 which showed no bleeding on the brain. He also noted that she had a two falls from her bed on November 4 and 6 and a fall from a hospital chair.

Mr Cadoux-Hudson said it was possible for the brain to accommodate a certain amount of blood for a while and added that it was a reasonable decision not to subject Mrs Gilmour to surgery as the outcomes of surgery for the elderly in cases like this are poor.

Counsel for the Gilmour family, Mr Sharp, asked the neurologist which fall from the hospital bed would have been more likely to cause the subdural haemorrhage?

Mr Cadoux-Hudson replied: “I have seen patients with acute subdural haemorrhage without any damage to the skin but I agree that an injury that causes damage to the skin is more than likely to have produced the haemorrhage. But it is possible that the haemorrhage formed on November 4 was exacerbated by the fall on sixth. I don’t think a CT scan could distinguish that. It’s not an exact science.”

Also giving evidence was Staff Nurse Nicola Dunn who was in charge of Medical ward 2 on November 5, 2007 and was providing care for Mrs Gilmour.

She said that Mrs Gilmour was “clearly identified to us as a being at high risk of a fall” so she was placed in a bed near the nursing station, in a low level bed with cot rails on the bed and given sufficient light around her bed.

She said she that on November 5 she heard a noise coming from the room Mrs Gilmour was in and found her lying on the floor. She reported that the cot rails remained up on the bed. An ice pack was administered to Mrs Gilmour’s head and a skull x-ray carried out.

Staff Nurse Dunn also added that Mrs Gilmour had not been able to get the cot sides down on her bed but had managed to get out through the gap at the bottom of the bed where the cot rail ended.

Counsel for the Gilmour family, Mr Sharp, told SN Dunn that a nursing expert would later tell the inquest that the believed it “inappropriate to use cot sides with confused elderly patients”.

SN Dunn replied that use of cot rails was “common practice for us at that time”.

Mr Sharp continued: “But if the cot sides hadn’t been up she could have come out of bed the normal way”. He said that cot rails had “forced her” to climb down to the bottom of the bed.

Counsel for the Northern Health Trust, Sean Smyth, then interjected saying that there was no evidence as to how Mrs Gilmour had fallen. “For all we know she got out of bed, was standing up and then collapsed.”

Mr Smyth than asked SN Dunn to confirm that Mrs Gilmour had been identified as a high risk of fall, that a system was put in place to create a safe environment for her and that this system, was successful from October 25, when the patient was admitted, up until November.

“Yes,” she confirmed.

Next to give evidence was nursing expert Robin Mudford MSc RGN RMN who spoke via video link from London.

He told the inquest that he had compiled a report into Elizabeth Gilmour’s case which found that “the fall could have been foreseen and prevented”.

He claimed that the nursing care failed to “properly assess the risk of falling, to properly assess the risk of using cot rails, failed to review the use of cot rails after Mrs Gilmour’s previous falls and failed to maintain a safe environment”.

He added that the standard of care “fell below the standard expected” and also claimed that a “poor standard of record and record keeping had contributed to Mrs Gilmour’s substandard care.

Mr Mudford also added his opinion that cot rails should not be used with elderly confused patients as they lead to them feeling “trapped” especially at night.

Counsel for the Northern Trust, Mr Smyth challenged Mr Mudford about his claims regarding nursing care.

He said that while Mr Mudford might not personally agree with the use of cot rails they had been part of the system of dealing with fall-risk patients at the time.

He stressed that they had been used in conjunction with low level beds and placing Mrs Gilmour close to the nursing station. “Was that commendable?,” he asked Mr Mudford.

“Yes,” replied Mr Mudford.

Mr Smyth quoted from the staff’s medical notes. “They constantly refer to the risk faced by Mrs Gilmour. In fact, 15 times they mention the risk of falling and the need for observation,” he stressed.

Last to give evidence was the Northern Trust’s Head of Governance and Patient Safety Hazel Baird who had chaired the Trust’s internal inquiry into Elizabeth Gilmore’s death.

She quoted from a Trust response to Mr Mudford’s criticism of nursing care given.

She said that a full risk care plan had been detailed by staff and steps had been taken to ensure the safety of Mrs Gilmour using the tools available at the time.

She said that since Mrs Gilmour’s death and another “serious adverse incident” in the Trust, a new tool had been implemented by the Northern Trust.

She said that there were risks associated with using cot rails and risks with not using them.

Mrs Baird said there was a new risk assessment pro forma now in use allowing a balanced assessment for the use of cot rails but “it still requires an element of judgement.”

She said the patient’s family could be consulted but it would still be “essentially a nursing decision”.

Mrs Baird went on to explain that since Elizabeth Gilmour’s death the Trust secured funding to purchase new “low entry beds” which are six inches lower than those formerly used in the Causeway Hospital. They can also be used with bed rails.

She said that the Trust, within limitations, had identified Mrs Gilmour’s needs and created a care plan for her. She said they very much regretted that Mrs Gilmour sustained a head injury which resulted in her death but added that the Trust had learned from the incident and made” substantial improvements”.

In conclusion, Coroner Brian Sherrard found that Elizabeth Gilmour had been found on the floor beside her hospital bed. He said that position in which she was found and her injuries suggested that she fell from the bottom of the bed.

He said there was no criticism of the care given to Mrs Gilmour by staff at the Causeway Hospital and no criticism of the record keeping or notes made by the staff which, he said, were “voluminous”.

“The Trust has helpfully accepted that there were certain system deficiencies regarding tools available to staff at the time and these matters have been addressed.

“While it is impossible to exclude all risk, I am satisfied that these measures are sufficient to deal with similar situations in future.”

He said Elizabeth Gilmour’s death was not an outcome anticipated or desired by the Trust. He also praised the Trust for the forthright way they had addressed any deficiencies that had become apparent after Mrs Gilmour’s death.

He finished by offering his condolences to Elizabeth Gilmour’s family.