Dennis Price

I am Ms N J Mundy, Senior Coroner for South Yorkshire East

On 11 November 2024 I commenced an investigation into the death of Dennis Keith Price. The investigation concluded at the end of the inquest . The conclusion of the inquest was: Accidental death Subdural haemorrhage Fall

This case relates to the death of Dennis Keith Price a 71 year old male who passed away on  28th October 2024 following admission to the Doncaster Royal Infirmary on the 24 th October  2024 due to acute limb weakness and being unable to weight bear. On the 28 th October in the afternoon, he suffered a fall when making his way unescorted to the toilet. There was  some delay in him being attended to by nurses and helped him to bed and doctor’s  assessment shortly after that revealed a Glasgow Coma Score of 15. The inpatient post falls  review was not fully completed in that there was no indication as to whether the question with  regard to head injury was ‘yes’ or ‘no’ or ‘don’t know’. There is no reference to Mr Price’s blood thinning medication being a factor. There was no clear direction from the attending  doctor as to the frequency or neurological observations which were merely stated to be that  he was to be observed for two hours. Furthermore, the recorded (and deteriorating) Glasgow Coma Score triggered three escalations through the Nerve Centre System the first of which  was not completed until several hours (the following morning) after the alert triggered. As it was, between Glasgow Coma Score checks there was a catastrophic deterioration when he dropped from a score of 13 to 6 leading to Mr Price passing away later on that evening on the 28 th October from a subdural haemorrhage.

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:

1. Failure to properly complete the inpatient post fall review.
2. No clear plan for frequency of neurological observations and duration of the same and

associated lack of clear direction from the attending Doctor following a fall.

1. The efficiency of the Nerve Centre system escalations in that any triggers must be

followed up and properly completed on the system for the nerve centre system to be  fully effective.

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