Maria de Ceita

I am Mr P. A. Murphy, Area Coroner for the coroner area of the Northern District of Greater London

On the 05 July 2023 I opened an investigation touching upon the death of Maria Francisca Teixeira de Ceita, aged 87 years old. I opened an inquest on the 27 July 2023. The inquest concluded on the 16 February 2024. The conclusion of the inquest was: “Maria de Ceita died as a result of brain damage caused by an unwitnessed fall while she was a hospital in-patient on 04 July 2023”. The following factors contributed to her death: a) Not recording that Ms de Ceita required one-to-one supervision on the ward; b) Not recording an update to that plan; c) Not putting in place one-to-one supervision on the 3-4 July 2023; and d) Lack of effective communication between staff on the ward.

Maria de Ceita was born on the 26 March 1935 in Goa, India. She was 87 years old when she died on 04 July 2023 in North Middlesex Hospital, as a result of an unwitnessed fall earlier that day by her hospital bed, which caused her a fatal brain injury. Ms de Ceita was known by the hospital to be at risk of falling and at the time of the fall she should have been under one-to-one supervision by hospital staff.

CORONERS CONCERNS The MATTERS OF CONCERN are as follows. – In view of Ms de Ceita’s known risk of falling, staff at the hospital decided to put in place one-to-one supervision. An omission in recording that plan in Ms de Ceita’s medical records by hospital staff led to that plan being affected which in turn led to Ms de Ceita subsequently falling by her hospital bed and sustaining a fatal brain injury. The matter of concern is therefore the lack of an effective system to document and address the risk of elderly patients falling while in the hospital.

In my opinion action should be taken to prevent future deaths and I believe you and your organisation have the power to take such action.