A frail, elderly man with dementia died after falling from a trolley in a Whiston A&E waiting room.
Richard Smith, 90, was taken by ambulance to Whiston Hospital on December 26 2020 after he was found on the floor of his bedroom at the Key Healthcare-owned care home were he lived. He suffered minor cuts and was taken to A&E for a check-up and CT scan, and was placed on a trolley in a cubicle at 6.20pm.
At 6.50pm, the dad-of-three was found on the floor outside the cubicle, having fallen from the trolley, breaking his left hip.
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At his inquest today, April 4, the court heard that Mr Smith, a retired mechanic, had been looked after by his family at his home on Cranshaw Avenue, St Helens, until December 1 2020, when he was admitted to Whiston Hospital. He was transferred to a care home on December 24, where he fell from his bed just two days later.
Following his subsequent fall at Whiston Hospital, he underwent surgery for a broken hip on December 27. On January 3 2021, he suffered a gastrointestinal bleed - bleeding inside the digestive tract. His condition continued to decline, and he was placed on palliative care. He died on January 19.
Whiston Hospital emergency department matron Susan Hobbs said Mr Smith had been classed as being at high risk of falling, and that he needed "one-to-one care, or if not that, one-hourly checks". However this did not happen, and nurses were unable to say when the 90-year-old fell from his trolley.
There had also been "a significant delay" in the hospital's investigation into the incident, as it had not been properly reported.
She said: "We knew an incident report was completed, that Richard had fallen and sustained a fracture, but that was never escalated up the line and the senior manager was not aware. It wasn't until later on that we learned Mr Smith had suffered a fracture."
She added: "I spoke to the nurse that had looked after Mr Smith and she couldn't give a reason why she didn't escalate it and it was a lesson learned for her. We did some reflection and she understands the catastrophic impact it had, because investigations weren't started promptly."
A number of changes have been put in place at both Key Healthcare and Whiston Hospital to prevent further incidents since Mr Smith's death in 2021. Key Healthcare operations manager Lin Spencer said risk assessments in all the provider's homes are now "more robust", and that sensor mats had been put down to alert staff should residents fall out of bed.
Ms Hobbs said documents at the hospital had been updated and shared with staff, and that low trolleys had been placed in A&E to prevent further fall injuries.
Coroner Julie Goulding handed down a conclusion of accidental death.
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