Anger at death of Harold Wonfor at William Harvey Hospital
00:01, 22 February 2018
A family say they are yet to receive an apology after a grandfather was among five patients who fell and died on the same hospital ward within the space of just four months.
Harold Wonfor was admitted to the William Harvey Hospital in January last year after he suffered an infection and became delirious.
The 78-year-old retired plumber was taken to the Cambridge Ward which provides palliative care and care for vulnerable patients.
But despite having suffered falls when he was in hospital in Canterbury in the preceding month, no assessment was carried out, and within 30 minutes of his arrival he got out of bed and suffered a fall where he hit his head against a sink.
At Mr Wonfor’s inquest in September last year a verdict was recorded that he had suffered an accidental death from a blood clot on his brain.
Assistant coroner Kate Thomas found that Mr Wonfor’s history of falls had not been recognised, and found no assessment had been carried out within either six hours or 24 hours of his arrival, in breach of the hospital’s policy.
She also found that there were four other similar deaths between January and April 2017 with patients dying after suffering falls.
These were so serious that Ms Thomas wrote to the East Kent NHS Trust (EKHUFT) with a Regulation 28 report to demand action to prevent future deaths.
In the report the she noted: “At the very least Mr Wonfor should have been met by a nurse upon arriving at the ward and placed in an observation bed. This did not happen.
“Approximately 30 minutes after arriving on Cambridge L Ward, Mr Wonfor had an unwitnessed fall… from which he subsequently declined and died.
“Five deaths occurred at the Cambridge Ward at the William Harvey Hospital.
"Common to each was the fact that the death was caused by a fall on the ward in circumstances where falls risk assessments were either inadequate, incomplete, not reviewed or not enforced.”
The report recognised that by the time of the inquests held last autumn, significant improvements were being made, and the trust’s chief executive had until mid-January to reply to the findings.
The family of Mr Wonfor submitted a formal complaint to the East Kent NHS Trust, and say they only found out about his fall at his inquest nearly nine months later.
"I left my dad thinking he was going to be safe in hospital, but because of the lack of care he died" - Damion Wonfor
In their complaint they said: “As a family, it has been very hard to come to terms with the loss of Harold, particularly as his death was due to a preventable fall.
“At the very least, we expected that staff would follow safety policies to keep him safe as is their duty of care.
“We believe that a CT scan should have been carried out due to striking his head on a sink.”
No CT scan was carried out after his fall as one had already been done at the Kent & Canterbury Hospital in the previous month.
Mr Wonfor’s son Damion added: “I left my dad at 3.30am in the morning, thinking that he was going to be safe in the care of the hospital, but because of the lack of care he died.
"I’m furious, the trust has never once apologised.”
The family hope that their formal complaint will help prevent other families having to go through a similar experience in the future.
East Kent NHS Trust interim chief executive Susan Acott said the rate of deaths from falls at the William Harvey Hospital is below the national average and that the hospital has one of the best performances in the country for preventing falls.
She said the trust had reviewed its Falls Risk Assessment and Care Plan in the wake of the assistant coroner’s report, and said the trust has developed the Fallstop programme to find new measures to improve care.
In a letter to the coroner, she wrote: “I can reassure you that we have taken on board your comments and will continue our commitment to deliver a safe and effective service to our patients.”
Trust spokesman Steve James said: “The National Institute for Health and Care Excellence has seven key areas that set out what hospitals need to do to prevent falls.
“Our hospitals’ performances against these key areas are nationally reported every year, and last year the William Harvey Hospital was the fourth best performing in the country.
“We take falls prevention extremely seriously and we are continuing to implement further measures to prevent falls under the Fallstop scheme.”
He added that the CQC had been assured the trust is taking the appropriate action and demonstrating good practice.
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