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November 30, 2010

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Investigation slams hospital’s staffing levels following patient fatality

An elderly patient suffered fatal injuries after falling from his hospital bed despite his family warning staff that he required bed rails.

Francis Steele, 89, was a patient at Telford’s Princess Royal Hospital, operated by Shrewsbury & Telford Hospital NHS Trust, when the incident took place on 21 November 2007.

Mr Steele’s son informed the hospital that he required bed rails, as he had previously fallen out of his bed at home. A senior nurse agreed to install the rails but was only able to find one rail and made no attempt to look for a second. As a result, Mr Steele fell out of the open side of the bed and landed on the floor. He suffered a head injury, from which he died ten days later.

Shrewsbury Crown Court heard that hospital staff did not know where to find the rails, as there was no system of storage. It also heard evidence that staff were unable to look for another rail later in the shift, as the ward was grossly understaffed.

HSE inspector Lindsay Hope said: “Shrewsbury & Telford Hospital NHS Trust’s failure to provide a bed rail for a frail, vulnerable patient, who urgently needed it, is unacceptable.

“The failure was compounded by chronic staff shortages. Just a few weeks before this incident, one nurse was so concerned by staffing levels in the ward she had written to the trust board, but no action was taken.

“The Trust’s own policy was not to trigger any action on staff shortages until the levels became ‘high risk’. As a result, the trust was typically working at ‘high risk’, or ‘very high risk’.

Shrewsbury & Telford Hospital NHS Trust appeared in court on 29 November and pleaded guilty to breaching s3(1) of the HSWA 1974. It was fined £50,000 and ordered to pay £8476 in costs.

The company had no previous convictions and fully cooperated with the investigation. Following the hearing, a spokesperson for the Trust said: “Our deepest sympathies are with Mr Steele’s family, and we have apologised for the failures that contributed to his death. The Trust fully accepted the findings of the inquest held in May and understood at the time that this matter would be progressed by the HSE.

“Since 2007, many improvements have been made to reduce the risk of this type of incident occurring again. This includes strengthening training to ensure all staff comply with a new bed-rail assessment policy, by ensuring that bed-rail assessments are undertaken and implemented.”

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