Rita Howells

I am Hugh Gregory Mark Bricknell, Senior Coroner for County of Herefordshire

On 10th May 2023 I commenced an investigation into the death of Rita HOWELLS. The investigation concluded at the end of the inquest on 10th July 2024. The conclusion of the inquest was Accidental Death.

Rita Howells was transferred to Bromyard Hospital on 6th March 2023 for rehab and discharge planning.  She became confused and agitated around 17th March 2023.  She was found to have a low grade fever and a raised CRP.  She was treated with antibiotics to cover for a possible chest or urine infection.  A CT head was requested as she had a fall from bed whilst on the ward. Rita Howells generally used a call bell but on the day she fell it was found not to be working.  Staff were aware. She had the CT scan on 23rd March 2023 which showed ‘acute cerebral haemorrhagic contusions at the right frontal lobe and also at the base of the frontal lobes on either side of the midline’ She was transferred to A&E that day and after discussion with the neurosurgical team it was deemed that this was to be treated conservatively. She deteriorated and following discussion with the family a palliative approach was implemented. Cause of death: 1a. Intracerebral Haemorrhage

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) Contrary to Policy as advised, bed rails are routinely erected before Falls Assessment (2) The procedures to establish whether a call bell is working are unsatisfactory

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