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A ‘sprightly’ 94-year-old admitted to hospital with a minor injury died from a brain haemorrhage after a series of catastrophic errors by experienced staff, an inquest heard.
Former civil servant Violet Wood suffered a fatal head injury at the Queen Elizabeth Hospital in Woolwich, south east London, while receiving treatment for a minor fall and infection.
Despite staff being aware of her potentially life-threatening condition, they failed to notice that her health was deteriorating dangerously until it was too late, the inquest heard.
Violet Wood, 94, died of a brain haemorrhage after falling and hitting her head in a hospital ward
The much-loved widow had been left alone in a room off a busy ward and had been allowed to sleep - a warning sign that she needed urgent medical attention for a cranial fracture, the hearing was told.
Her family said they have been left ‘gutted’ by the mistakes that led to her death.
Mrs Wood had spent two days on the hospital’s Acute Medical Unit (AMU) where she was being treated for dehydration and an infection in early 2012.
She had come to the hospital previously after falling at home, and was classed as a ‘medium’ fall risk by hospital procedures, the inquest heard.
Under the guidelines nurses need to be aware of where patients such as Mrs Wood are at all times, explain the risk to them and contact their relatives.
In the early morning of January 29, Mrs Wood, who had no history of dementia according to her GP, fell while walking around the ward and hit her head just after 3am.
Mrs Wood (pictured with her friend, George) was admitted to Queen Elizabeth Hospital, Woolwich, with a minor injury after falling at home but she never left the hospital
Earlier that day she had been adamant that she return home to her sheltered flat in Blackheath, south east London, telling staff: ‘I can’t stay here all day, I need to get things done.’
She was sent for a CT scan of her head and staff were expected to carry out regular ‘neurological observations’ as a precaution until a doctor was satisfied that brain scans showed she was OK.
However, nurses did not follow handover procedures and paperwork correctly, and the careful attention she required was missed.
Horribly bruised, Mrs Wood was eventually given a bed in a room off the ward, where she was left to fall asleep.
Nurse Olufunmilayo Afolabi-Shittu, who was caring for Mrs Wood, said she failed to raise the alarm until she ‘vomited big’.
The nurse said: ‘The situation then was, because I did not want to disturb her at that time. I wasn’t worried much about her condition.’
She had been tasked with checking her condition hourly but instead left her to sleep until checking on her at 16.30 that afternoon, the inquest heard.
When Mrs Wood hit her head, nurses failed to check on her so did not notice her condition was deteriorating
She said: ‘By the time I went back there initially she was coughing and threw up big, then I was really worried.’
Mrs Wood died the next day, with a post-mortem examination showing the cause of death as pneumonia and a haemorrhage from a fractured skull.
Nurses responsible for looking after Mrs Wood at the time admitted at an inquest at Southwark Coroner’s Court that there had been mistakes, but blamed the tragic lapse on a lack of available staff to take care of a number of ‘confused’ elderly patients wandering around the unit.
They claimed that rules about restraining patients meant that the accident would have been difficult to prevent and other measures would have been a greater risk.
During questioning by Assistant Coroner for Southwark, Sarah Ormond-Walshe, the team responsible for Mrs Wood’s care said they had learned from her death.
Senior Charge Nurse Greg Mirabona, who was in charge of the ward on the morning of January 29, said he ‘wouldn’t do the same again’.
By the time nurses realised how ill Mrs Wood was, it was too late to save her and she died the next day
When asked about the problem with staffing, he said: ‘I can say it’s much better now.
‘It has been increased now from what we originally did.’ He added that more staff were booked as a precaution.
However, Inge Vermeullen, a physiotherapist who had treated Mrs Wood, said there was ‘no way’ of avoiding cases like hers, adding: ‘Everything that we could have had in place was in place at that time.’
Speaking outside the hearing Violet’s niece, Karen Hills, 50, who is herself a bowel cancer nurse at the Medway Maritime Hospital in Kent, described her disbelief at the errors.
She said: ‘I just feel gutted as despite being profoundly deaf she still had an active social life with her friends and family.
‘I thought that whoever had been looking after her was junior and not very experienced.
‘However, they were both clearly experienced nurses who had been on the ward some time. To find out that they hadn’t grasped the severity or the potential severity of the decisions they have made, it’s horrible.
‘As a nurse myself it is drilled into us that you check on your patients, you follow the procedures, it’s your pin badge on the line or you end up somewhere like this.’
The hearing continues.
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