Beryl Farmer

1. There was also a failure to perform further neurosurgical observations after the

first set of observations before discharge.

1. At home, her condition declined and she developed headaches and was

readmitted back to Sandwell Hospital on the 1 July 2016. A CT scan was performed on this occasion and a subdural haemorrhage diagnosed.

1. Advice from neurosurgeons was sought and she was managed conservatively.

She then effectively remained in Hospital and went on to develop seizures as a result of the subdural haemorrhage and sadly died on the 30 August 2016. 5 CORONER’S CONCERNS 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. Evidence emerged during the inquest that Mrs Farmer had a risk of a falling

(moderate to high risk). There was no evidence that a falls risk assessment had been completed.

1. Given the risks of falls, there was no clear justification for moving her from a

monitored bay to an unmonitored bay.

1. After the fall, only one set of neurological observations were performed before

her discharge.

1. In addition no CT Head scan was performed despite evidence of significant

bruising to her face and head. 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you have the power to take such action.

1. You may wish to consider further training for all those involved in this incident in

respect of requirements for managing risks of falls.

1. In addition you may consider it is prudent in light of this incident to review your

policy on performing CT head scans particularly for those patients where there is evidence of bruising to the head area. 7 YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 20 January 2017. I, the coroner, may extend the period. Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise you must explain why no action is proposed. 8 COPIES and PUBLICATION I have sent a copy of my report to the Chief Coroner and to the following Interested Persons; Family and Care Quality Commission. I am also under a duty to send the Chief Coroner a copy of your response. [IL1: PROTECT]