‘Multiple contributing factors’ led to the death of a grandmother at Wexham Park Hospital, a jury has found.
The inquest into the death of Audrey Mills, of Manfield Close, Slough, was held from Monday, June 5, until Friday, June 9.
During the week, the jury heard how the 77-year-old died on January 8, 2016, as a result of a head injury sustained following a fall outside on January 6.
Based on the evidence, the jury found factors included ‘serious failures’ in oral and written communication and the relevant documentation not being made available to nursing staff resulted in a lack of one-to-one supervision for Mrs Mills.
In the summary of the verdict, it states: “Shift and ward handovers were inadequate and documentation was misleading in respect to the two DOLS orders (when Mrs Mills’ family agreed decisions could be made in her best interests on her behalf) and a Mental Health Assessment.
“These multiple failures, omissions and missed opportunities for one-on-one care to be implemented resulted in a serious accident which could have been avoided.”
In the summary, it states a Deprivation of Liberty Safeguards Assessment (DOLs) identified a specific need for one-to-one nursing supervision as Mrs Mills was at high risk of falls and unable to assess her own risks.
On January 6, Mrs Mills left her room unnoticed and unsupervised, and walked down an outside path, and fell. She was found at the bottom of a concrete stairwell. From the fall, she sustained a head injury which ultimately led to her death in the intensive care unit two days later.
On January 5, the day before the fall, Mrs Mills had been found in a hospital car park at 8.30am after leaving her room.
The conclusion states the ‘casual approach’ and lack of documentation in regards to Mrs Mills’ on-going falls risk assessment were a ‘serious contributing factor’ to her death.
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