Coroner criticises care home where 93-year-old woman died five days after falling out of bed

The family of an elderly woman who died five days after falling out of bed in a nursing home has criticized management.

An investigation found that 93-year-old Evelyn Jackson was seen as “low” risk of falling out of bed, so there was no railing to prevent it.

She had slept in a chair at the Abbeycrest Nursing Home in Sonning Common for four months because she was “afraid” that if she lay down, she would die.

But after her butt pressure ulcer was diagnosed, she was advised to go back to sleep in bed. About two weeks later, she fell out of bed in the early hours of the morning and hit her head, causing an intracranial hemorrhage that resulted in her death.

Assistant coroner Sonia Hayes has recorded an accidental death sentence but said she will write to the home to express concern about the risk assessment.

Ms. Jackson was admitted to the Kennylands Road home on February 28 with the consent of her family. She had lived in an apartment on Essex Way but was suffering from “cognitive decline,” the Oxford coroner heard.

Her daughter, Helen Walker, one of their five children, helped prepare a pre-admission care plan, which found that Ms. Jackson preferred to sleep in the recliner she took home.

The plan also said that for fear of dying alone, she did not want to be taken to the hospital in an emergency.

Ms. Jackson’s sleep regimen lasted four months until her family doctor and home support services advised her to sleep on her hips in bed to relieve the pain from the ulcers and the staff turned her every hour.

The risk assessment showed that she was only exposed to a high risk of falling while walking, so no restrictive measures such as bed rails, a fall mat or a lower bed were considered.

Sonia Da Silver, director of the home, told the investigation that bed rails should be viewed “carefully” because of the risk of them becoming entangled or a resident climbing over them.

If the risk of falling was assessed as high, the home would have required written permission from Ms. Jackson’s family as part of the custodial protections. Ms. Da Silva said: “The nursing staff recommended that Evelyn feels comfortable and shows no signs of discomfort in bed.

“It was a single bed, but she couldn’t turn on her own. She had to be [turned] by the staff to relieve the pressure and she was unable to walk at the time.

“It was a low bed and at the time the risk was identified the risk was low so we did not consider any restrictions. It was not considered necessary.

“The risks of bed rails can be dangerous if someone doesn’t like them and tries to jump or climb over them. She was found to have had a significant cognitive decline, but she was comfortable in bed and was checked hourly. “

Ms. Da Silva said Ms. Jackson was examined three times by nurses the night of her fall at 9:34 p.m., 10:19 p.m. and 11 p.m.

The fall occurred between midnight and 1 a.m. when she was found prone on the floor by a worker who set off the alarm.

The nurses checked her blood pressure and temperature and concluded that she was “okay and responsive,” but noticed a 1 cm cut on her forehead and a small cut on her nose.

Home called 999 at 1:25 am because the staff were concerned if Ms. Jackson suffered a head injury from taking anticoagulants for atrial fibrillation, which can cause profuse bleeding.

The paramedics directed the staff to keep her on the floor, and she was given a pillow and blanket and fell asleep again until an ambulance arrived at 6:30 am.

The ambulance crew advised the home to take her to the hospital, but her family said it was “very stressful” for her and she would be more comfortable staying at home.

Ms. Jackson was helped back to bed at around 8 a.m.

However, the family was dissatisfied when they came to visit later that morning and saw that the bed rail was not installed.

Ms. Walker, who lives in Sonning Common, said, “My brother visited her at 10:30 am and was very shocked when there were no bed rails, no fall mat and the bed up.

“They said they would wait for me to come in and sign a form, but I was never told. If I had known there was a form, I would have come in and signed it as soon as she went back to bed.

“Apparently you weren’t particularly prepared. My brother insisted on signing the form on the spot. The rails were finally set up, but it was too late. ”Ms. Da Silva, who has worked at the home for nine years and became general manager in March last year, said the rails would be put up as soon as the home had the family’s written consent.

She said Mrs. Jackson was only at risk of falling from one side of her bed, but couldn’t tell if the bed was against a wall or in the middle of her room.

Nor could she confirm whether an employee had been with her all the time.

Ms. Jackson died at home five days later on June 21. The official cause of death was intracranial hemorrhage caused by a fall due to her frailty and age.

Ms. Walker told the investigation, “How on earth? [wasn’t] Is she at high risk of just moving a little and going over the edge and bumping her head? I don’t understand the process that it poses no risk. She was fragile for her age, but the rails weren’t up. Why didn’t you hang up the bed rail right away? ”

The coroner said she accepted the medical cause of death but was concerned about how the home rated Ms. Jackson’s risk of falling out of bed as “low” when she was seen only asleep in a chair since she was admitted.

She said, “I share some of the family’s concerns about someone who is old and frail, who is taking these medications, who has not slept in bed for many, many months, and who has not been considered to be at risk of falling.

“I share some concerns that it has been classified as low risk. I’m satisfied that they did the risk assessment, but I don’t see how they came to that conclusion. ”She said that sleeping in a recliner is“ very different ”than sleeping in a bed and is more difficult to fall out of .

Ms. Hayes said the use of bed rails was a “difficult subject” as there have been cases where people were seriously injured or died because they became entangled in them.

However, the use of bed rails in Mrs. Jackson’s case did not result in her death. She added, “I know that losing a loved one is always painful. I think this family was concerned about the circumstances, but they accept that they were at the end of their lives. I have to emphasize that the use of bed rails must be carefully considered. “

After the hearing, Ms. Walker said the family were “immensely hurt and upset” by the circumstances surrounding Ms. Jackson’s death.

She said, “My mother’s death at 93 is not a tragedy, but the way she died is appalling and we believe Abbeycrest failed to fulfill its duty of care.”

Ms. Walker said Abbeycrest has still not offered condolences to the family.

“This lack of empathy made my mother’s death immeasurably difficult,” she said.

“I expected far better things from the management, considering how big the home they claim is.

“I think we want to acknowledge the difficult circumstances and perhaps express their regrets. I don’t think we’ll get an apology. “

An Abbeycrest spokeswoman said: “Evelyn has been a popular member of our home community, and our thoughts and compassions go with her family.

“We regularly review and update risk assessments based on history and active risk.

“In this case, Evelyn had to be repositioned in her bed by nurses every few hours due to her physical condition, as she could not do this on her own. There was no indication that their level of risk should be changed.

“The health and well-being of the residents is an absolute priority for us and we are always trying to support the family members and relatives of our residents during this very sad time.”

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