Renate Mark

I am Mr Andrew Hetherington  for Northumberland

On 1 May 2024 I commenced an investigation into the death of Renate MARK. The investigation concluded at the end of the inquest . The conclusion of the inquest was died as a result of a head injury sustained in an unwitnessed fall.

The deceased had considerable underlying natural disease. Within her home address on 20 April 2024 she  suffered  an  unwitnessed  fall.  She  was  conveyed  to  Northumbria  Specialist  Emergency  Care Hospital where a CT head scan showed age related atrophy and ischaemic changes but no other injuries. She was assessed as a level 3 falls risk meaning she was to be kept under line of sight in case of falling. She was stable and the plan was for discharge home with additional care support. At approximately 03:10 hours on 24 April 2024 she suffered an unwitnessed inpatient fall in the bathroom of room 25 on ward 9. She was not under direct observation despite her level 3 falls risk assessment. A CT brain scan identified she had sustained significant injuries including a cervical spinal fracture and a subdural haematoma as a result of the fall. Surgical intervention was not appropriate and that she received palliative care until her death within Northumbria Specialist Emergency Care Hospital at 22:25 hours on 25 April 2024.

During the course of the inquest the evidence revealed matters 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 MATTERS OF CONCERN are as follows [BRIEF SUMMARY OF MATTERS OF CONCERN] (1) The deceased was assessed as a level 3 falls risk meaning she was to be kept under line of sight in case of falling. Witness statements served in advance of the inquest stated the fall was witnessed. It was  however eventually  accepted in  evidence  that the  fall  was in fact  unwitnessed.  The precise circumstances of the fall could not be determined. All of the investigations undertaken by the Trust relied upon the incorrect understanding that the fall was witnessed and observations were in line with Trust falls policy, when they were not. (2) The inquest heard that it is practice within the Trust that a Nursing Assistant is to be located  centrally in the corridor on ward 9 to oversee patients assessed as at risk of falling and for the patients to be within staff’s peripheral vision. The inquest heard that on 24 April 2024 8 patients were  assessed as level 3 falls risk and 1 patient  was assessed as level 4 falls risk. I am concerned as to the number of patients  at  risk  of  falls  being  observed  in  this  way.  I  am  further  concerned  that  there  is  a misunderstanding  of  what  is  meant  by  peripheral  vision  and  what  constitutes a  witnessed  or unwitnessed fall. (3) I am concerned there is not greater scrutiny of witness accounts as part of the Trust’s investigation process in particular given the concerns raised by the deceased’s family early in the investigation and the other witness accounts to provide earlier learning to prevent future events.

In   my   opinion   action   should   be   taken   to   prevent   future   deaths   and   I   believe   you CHIEF EXECUTIVE OF NORTHUMBRIA HEALTHCARE NHS FOUNDATION TRUST  have the power to take such action.