Margaret Maycroft

I am David Donald William REID, HM Senior Coroner for Worcestershire.

On 31 January 2024 I commenced an investigation and opened an inquest into the  death of Margaret Rose MAYCROFT. The investigation concluded at the end of the inquest on 12 September 2024. The conclusion of the inquest was that Ms. Maycroft “Died from natural causes, to which injuries sustained in a number of recent accidental falls contributed.”

In answer to the questions “when, where and how did Ms. Maycroft come by her death?”, I recorded as follows: “On 18.12.23 Margaret Maycroft, who had recently suffered a number of falls at home, which had caused an intracranial bleed, and on a hospital ward during a previous  admission, was readmitted to Worcestershire Royal Hospital and found to have  suffered an ischaemic stroke. During this admission, she suffered two further falls and  was found to have sustained a displaced fractured neck of femur. She underwent  surgery to repair this fracture, but thereafter continued to decline. She was transferred  to the Princess of Wales Community Hospital, Bromsgrove for palliative care, and  declined and died there on 27.1.24.”

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) While at Worcestershire Royal Hospital, Ms. Maycroft sustained a number of falls: a) on 5.12.23 in the Emergency Department; b) on 19.12.23 in the Emergency Department; c) on 23.12.23 in the Acute Frailty Unit. 2) In respect of each of these falls, Matron [REDACTED] gave evidence that whilst staff in the Emergency Department and the Acute Frailty Unit had  completed falls risk assessments, no measures to mitigate that risk, such as  might be found in a falls prevention, assessment and intervention plan, were  documented in Ms. Maycroft’s notes. This meant that no documented falls  prevention measures were put in place for her. 3) Furthermore, I heard no evidence at the inquest which satisfied me that steps have now been taken to ensure falls prevention measures are now being  properly considered and documented in both the Emergency Department and the Acute Frailty Unit at the hospital.

In my opinion action should be taken to prevent future deaths and I believe you, as the Chief Executive of Worcestershire Acute Hospitals NHS Trust have the power to take such action.