Margaret Daly

I am John Adrian Gittins, Senior Coroner for North Wales (East and Central)

On the 14 th of June 2024 I commenced an investigation into the death of Margaret Joy Daly (DOB 23.10.32 DOD 10.6.24). The investigation concluded at the end of the inquest on the 24 th of October 2024. The cause of death was recorded as being due to 1(a) Traumatic subdural  haematoma (b) A fall 2. Delirium and the conclusion of the inquest was that the death was due to an accident.

The circumstances of the death are that Mrs Daly had been an in-patient at Wrexham Maelor  Hospital and as a result of her being assessed as being at significant risk of falling she was on an enhanced level of observation. On the evening of the 1 st of June 2024, Mrs Daly was exhibiting signs of anxiety and agitation and a member of nursing staff asked a doctor to review her. As the doctor was too busy to attend the ward, the nurse took Mrs Daly’s prescription chart to the doctor on another ward and he  prescribed a sedative, namely lorazepam which was administered to her at 22.40 that evening  with a further dose being given at 04.30 the following day. Later that morning Mrs Daly had an unwitnessed fall and sustained the injury which resulted in  her death. The evidence supports a view that it is probable that she fell as a result of the effects of the sedation.

During the course of the inquest the evidence revealed the following matter giving rise to  concern. In my opinion there is a risk that future deaths will occur unless action is taken. In the circumstances it is my statutory duty to report to you. The MATTER OF CONCERN is as follows.  – The clinician who prescribed a sedative, did so, without reference to any of Mrs Daly’s notes  other than her prescription chart and as a result was unaware of her enhanced falls risk or any  other behavioural issues. Whilst I recognise that medication changes may be necessary without the doctor being able to review a patient in person, I am concerned that this may occur without the doctor having access to and considering her full medical records and risk assessments.

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