Norma Bruton

I am Vanessa McKinlay, Assistant Coroner for Birmingham and Solihull

On 3 November 2022 I commenced an investigation into the death of Norma Winifred BRUTON. The investigation concluded at the end of the inquest . The conclusion of the inquest was; Natural causes contributed to by injuries sustained in a fall.

The deceased was admitted to Birmingham Heartlands Hospital on 13 October 2022 for treatment of a pneumothorax with a background of pulmonary mycobacterium infection and chronic obstructive lung disease. An assessment of her risk of falling did not take into account the presence of a chest drain and an intravenous drip and Mrs Bruton was assessed as being able to mobilise independently. She had an unwitnessed fall on the morning of 15 October 2022 when trying to walk the short distance to her bathroom and sustained a right fractured neck of femur for which she underwent surgery on 20 October 2022. Mrs Bruton’s condition deteriorated after the surgery and she died in hospital on 22 October 2022. Based on information from the Deceased’s treating clinicians the medical cause of death was determined to be: 1a Sepsis 1b Hospital acquired pneumonia 1c II   Chronic Obstructive Lung Disease, Frailty, Neck of femur fracture (operated), Pneumothorax

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. The Birmingham Heartlands Hospital falls risk assessment document does not prompt staff to consider or document the presence of attachments such as chest drains or intravenous infusions.
2. The document does not prompt staff to comment on the relevance or otherwise of such attachments when assessing the risk of falls.
3. Where attachments are documented on other forms (for example, the manual handling assessment form), this does not prompt the staff to reconsider the falls risk assessment.

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