A 76-year-old resident who died after falling at Springfield Grange Nursing Home, where she was staying after being discharged from hospital, died by accident, the coroner John Needham has ruled.
Winifred Howard died from a head injury on April 4 this year after falling in her room at the home the previous morning.
Mr Needham told the court Mrs Howard had battled through a serious case of pneumonia before being released to respite care for a few weeks at Springfield and was due to have gone home on April 5.
Though she was assessed as being at high risk of falling, compared with many of the home’s residents, Mrs Howard’s mobility was said to be good.
The court heard she had a range of medical problems and had mentioned being occasionally unsteady on her feet. Evidence was also given that she favoured slip-on slippers and her pyjamas were too long, needing to be rolled up.
In addition her bed, at its lowest height setting was still too high for her to climb up into without help. She was described as independent and sometimes unwilling to use the alarm bell to call staff to help her.
In evidence, one of the home’s nurses, Leslie Tan, said: ‘She was a lovely person and didn’t want to complain or ask for help. We encouraged her to ask for help and use the bell if she needed anything but she was more mobile than many of our residents and she was also compos mentis – very alert.’
On the morning of Mrs Howard’s accident, Mrs Tan said she was in the corridor outside Mrs Howard’s room around 8.20am when she heard a loud bang and a cry of pain.
She said she and two other staff helped Mrs Howard into a chair from the spot where she had fallen. She was conscious and alert but had banged her head and hurt her arm. An ambulance was called.
In hospital her condition deteriorated and a scan showed she had a subdural haematoma, which was not treatable.
Delivering his verdict Mr Needham said: ‘I am satisfied that there is a difficult balance to be made between dealing with a resident’s freedom of movement and autonomy and against keeping them immobile except under supervision from staff.
‘One can never rule out risk completely without interfering with freedom.’
Mr Needham said there was no evidence of Mrs Howard ringing for help and not being attended to, nor did it seem the fall was caused by the height of her bed.
He said evidence suggested residents’ medication records were not always as detailed as they could be – for example the precise number of pain-killers given was not always shown – but there was no suggestion Mrs Howard was drowsy from too many pain killers.
The fall, Mr Needham said, could have resulted from unsuitable slippers, which Mrs Howard herself had blamed for the fall.
‘This fall could have happened at any place.
‘It is not due to any systematic weakness in procedures at Springfield. Unfortunately once Mrs Howard had banged her head no intervention would have saved her,’ Mr Needham said.
He added in different circumstances the deficiencies in Mrs Howard’s medical records kept by the home could have been serious but in this case were not material to her death.
‘I will be referring the matter of defects in the records to the Regulations and Inspection Unit to ensure steps indicated by the matron today are being taken.’
He told Mrs Howard’s family: ‘I am sure she was a nice and pleasant lady who all the staff seemed to get on with. My condolences for your loss.’