THE death of a woman who banged her head when she fell over in a Hillingdon Hospital ward has been ruled accidental.
Jean Gill, who lived in Tudor Road, Hayes, died in the early hours of July 14, 2011, hours after suffering a brain injury in Churchill Ward.
At an inquest into the death of 77-year-old Mrs Gill, the care she received and her medication came under the spotlight.
Coroner Lorna Tagliavini, reading a letter from the family’s solicitor, said: “The family are concerned that there was no supervision or monitoring, and Mrs Gill was unlikely to remember any instructions about her mobilisation.
“They believe that if supervision had taken place and measures put in place to prevent harm, she wouldn’t have died in the way she did.”
The inquest, at West London Coroner’s Court, heard that Mrs Gill had suffered from chronic pain in her ribs after falling from a bus 14 months before, and was admitted to the hospital’s accident and emergency unit on the evening of July 12.
Senior staff nurse Helen Yates was working in the emergency assessment unit when Mrs Gill was transferred there at about 3.30am on July 13. She told the inquest Mrs Gill scored low on a falls risk assessment. “She was independent in most activities, but required a bit of assistance,” the nurse added. “She needed home help, but could eat and drink herself.”
The court heard that the assessment was based on several factors – visual impairment, whether the patient was agitated or had a history of falls, and whether she was independently mobile – all of which were favourable.
Physiotherapist Holly Thompson, who assessed Mrs Gill, confirmed she required ‘minimal assistance’, but she was given a walking frame to ‘improve independence and increase confidence’. “She was very frail lady. She had reduced muscle endurance and supervision was appropriate, but her orientation and balance were fine,” said Mrs Thompson.
Mrs Gill was given a number of painkillers during her stay, including Tramadol, paracetomol, a Lidocaine patch and Oramorph. Questions were asked about whether she showed side-effects, such as dizziness or hallucinations, that could have increased the chances of a fall.
She was observed two hours before the fall and records showed her readings and behaviour were normal. It is believed she was attempting to get out of bed to assist another patient when she fell.
Recording a verdict of accidental death, Mrs Tagliavini said: “On the balance of probabilities, there has arisen a misunderstanding of what pain relief Mrs Gill was prescribed, and this was a possible source of confusion, but I find it unlikely that the pain relief left her confused and hallucinating.”
A spokesperson for the Hillingdon Hospitals trust: “In reaching a verdict of accidental death the coroner found the care provided by the trust’s staff was appropriate. We will consider the report carefully in order to identify any further learning points.”