A Buncrana man died of complications as a result of a head injury after falling out of bed at Letterkenny University Hospital, an inquest into his death has found.
Clinical handover procedures at the hospital have been upgraded since the death of Raymond Sweetman last July after a healthcare assistant was not informed that the patient, who fell onto the floor from a bed, was a “falls risk”.
Other measures have since been put in place at the facility after a working sensor mat could not be found when Mr Sweetman was transferred between rooms in Medical 2 in May, 2023.
Mr Sweetman was 74 years old when he passed away at Letterkenny University Hospital on July 7, 2023, six weeks after suffering a fall in the hospital on the morning of May 26.
Dr Denis McCauley, the coroner for County Donegal, said at the begining of the inquest, which was held at Letterkenny Coroners Court, the issue was that Mr Sweetman had a fall which may have contributed to his eventual death.
After hearing the deposition of healthcare professionals, Dr McCauley said it was his view that Mr Sweetman died as a result of a head injury due to a fall.
“It was an accident that caused a vulnerable person to die and that is regrettable,” Dr McCauley said.
Dr McCauley said lessons had been learned from the matter. While, he said, the family of Mr Sweetman would have preferred for this not to have happened, it was now preferable that lessons were learned.
The coroner said that simple things such as the availability of straightforward appliances which decrease the risk of things happening should always be freely available to healthcare staff.
“That is vital and there have been actions taken,” Dr McCauley said.
“There is a recognition that all people who are caring for vulnerable persons should have full information so that they can give the best care that they can. I applaud the fact that that has been recognised and is now taking place.”
Ms Ann Drake, Director of Nursing at Letterkenny University Hospital, was asked during the inquest about approaches taken to ameliorate risks associated with patients who are classified as being a high fall risk.
Sensory alarms and/or cot sides are utilised “if appropriate” and other measures, such as a mattress being placed on the floor and the bed being in the lowest possible position, can also be taken.
In relation to the absence of a sensory alarm in the case of Mr Sweetman, Ms Drake said: “Unfortunately we couldn’t find a sensory alarm. Many were broken.”
As a result of this incident, Ms Drake said there have been measures in place to make sure there is an adequate supply of sensory alarms for all wards.
Ms Drake said a risk assessment of Mr Drake’s situation showed that 15-minute reviews, as opposed to one-to-one nursing care was adequate.
The clinical handover policy at the hospital has been reviewed and all healthcare assistants are now included in this process.
“Now, all health professionals dealing with a patient get as much information as possible,” Ms Drake said.
Professor Ken Mulpeter, Consultant in Geriatric and Internal Medicine at LUH, told how Mr Sweetman had been a patient under his care since 2011.
He recalled how Mr Sweetman previously spent 130 days in rehabilitation following a stroke before he suffered another stroke in January, 2023 and never regained his previous mobility.
Following a fall, he was readmitted to Letterkenny University Hospital on May 24, 2023.
Prof. Mulpeter said it was his opinion that the fall suffered by Mr Sweetman in Medical 2 at the hospital “directly related to a traumatic brain injury” and was the reason for the deterioration in his condition.
Cot sides were not a “fail safe” for patients who are a fall risk, he said, so beds are to be kept as low as possible. A mattress placed beside the bed would help to cushion a fall in the event a patient did sustain a fall.
Prof Mulpeter told the inquest how he adopted a palliative approach due to the deterioration in Mr Sweetman’s condition.
He said he would have recommended one-to-one care due to “the unpredictability” of a person in a condition such as that experienced by Mr Sweetman. Prof Mulpeter told Dr McCauley that this one-to-one care would be “day and night”.
Prof Mulpeter said it was his view that Mr Sweetman “died as a result of a brain injury”.
Healthcare assistant Colette Maloney said in a deposition read to the inquest by Dr McCauley that she was on duty in Medical 2 on the night of May 25, 2023 into the morning of May 26, 2023.
Ms Maloney said the bed was low and the cot sides were up at all times in relation to Mr Sweetman.
Ms Maloney recalled starting rounds at 6am and an enema being administered to Mr Sweetman at around 6.15am. She said Mr Sweetman was repositioned in the bed and was “comfortable and showed no signs of distress”.
When she passed the room at around 6.40am she noticed Mr Sweetman moving his shoulders and she went to a trolly to get some toiletries.
This “took a split second” and upon her arrival back she found Mr Sweetman laying on the floor.
“It all happened so quickly,” Ms Maloney said, adding that she did not hear the fall.
Mr Sweetman was lying face down on the floor when Ms Maloney returned and a doctor arrived “within seconds”.
Ms Maloney said she was informed at the start of her shift that Mr Sweetman was “bed-bound” and was not informed that he was a falls risk.
Ms Maloney told Dr McCauley that if she were told he was a risk of falling, that he would have been observed more “and preferably be one-to-one observation with that patient”.
“If they are bed-bound, you’d think they wouldn’t be able to fall,” she said. Had she been advised in advance he was a falls risk, she said she would have stayed and got someone else to get the toiletries.
Debbie Hay, a clinical nurse manager on the ward, said she was not on duty at the time Mr Sweetman suffered the fall, but told the inquest how she was on duty on May 25, 2023 and received a handover.
Ms Hay said Mr Sweetman had been identified as being a high falls risk. She told Dr McCauley that “we were aware that Raymond did take two people”.
She told how a number of factors are taken into account in such assessments, including a patient’s mobility needs, the wearing of appropriate footwear, their orientation on the ward, hearing aids, visual aids and a delirium assessment.
Ms Hay said Mr Sweetman was moved to a room closer to the nurses’ station as an additional control measure.
She said a mattress was beside the bed in the previous room Mr Sweetman had been in and a sensory mat was not available following his move.
“If one was available, it would’ve been used,” she said. Ms Hay said all staf should be aware, as part of a care plan, if a patient is deemed a falls risk.
Ms Hay agreed with Dr McCauley that the mattress was used in the previous room as an “optional extra and “some form of extra protection”.
Asked by the coroner if a sensory mat was part of the plan for Mr Sweetman, Ms Hay replied: “Ideally”.
Ms Hay said she wouldn’t have classified Mr Sweetman as “bed-bound” and would have said he needed the assistance of two people when being moved around.
Mr Sweetman’s family said they had expressed concerns following his transfer to the room in which he was moved to, pointing out that there was no sensory mat included.
The Sweetman family asked why notes accurately showing Mr Sweetman’s state had not been handed over to the healthcare assistant.
“We know that that didn’t happen and it’s an important fact,” Dr McCauley said.
“If they had those notes, things might have been done differently,” Mr Sweetman’s widow remarked.