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'Major nursing changes' after hospital failures lead to two deaths


A hospital has introduced “major changes” to its nursing care after a coroner said a catalogue of failings had led to the deaths of two patients, its chief nurse said today.

Brian Waller, 72, died after falling out of bed at the Royal Sussex County Hospital in Brighton, East Sussex, in April last year. A month later Edward Warneford, 66, died in the same ward after choking on his false teeth.

Mr Waller, who was being treated for heart problems, fell out of his hospital bed despite wearing a wrist band with “risk of falls” written on it.

He landed on his head, breaking his neck and suffering a massive bleed on his brain which led to his death six days later.

It was later discovered that one of the guard rails on his bed had been left down.

At inquests into the two men’s deaths, coroner Veronica Hamilton-Deeley strongly criticised Brighton and Sussex University Hospitals Trust and said changes needed to be made at the hospital.

Sherree Fagge, chief nurse for Brighton and Sussex University Hospitals, admitted staff could have done better.

She said in a statement: “The circumstances surrounding the deaths of these two patients were very different.

“However, what I see when I am on the wards is that the majority of our nurses are working hard and carrying out their duties with the kindness and compassion we would want for our own families but we are also using this as a way of teaching our less experienced nurses and picking up issues before they become problems.”


Readers' comments (22)

  • Have these people actually ever dealt with a confused, elderly person who is determined to climb over the side rails? You can show them how to use the call bell 150 isn't going to sink in.

    You have two options if you want to stop these people from falling out of bed. Number is restraints. But they are illegal in the UK. Number 2 is providing a one to one. Someone needs to pay for a carer to sit with that patient day or night.

    These are the only two things that will work. Staffing the wards with 2 nurses and 2 care assistants to 40 patients (20 of whom are fall risks) and then saying that morse scores will do the trick is disgusting. A fall risk wristband? Really?

    I cannot believe that this woman is trying to blame nurses for being unable to control an uncontrollabe situation.

    When my grandmother in New Jersey became confused and aggressive with a UTI she was admitted to hospital and put in soft point restraints during the times when family members were not able to be there. I knew darn well that her Nurse with multiple other patients would have found it physically impossible to stop grandmom from climbing over the bedrails and falling. I'm a nurse and I have been there. I know what they have on their plates.

    As antibiotics kicked in and she became more lucid she was taken off of the restraints.

    She got better and went home. Then we took her on a vacation of a lifetime.

    If she had been in the UK I am sure she would have died of a head injury. Oh but at least the morse scores would have been done and documented.

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  • I also find in the UK that it tends to be the medics who walk away from patients and leave the cot sides down.

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  • The other thing that is being used in other countries are bed alarms. These things alarm very loudly when a patient tries to get out of bed. This allows the Nurse to run down there and prevent a fall, as long as she isn't in the middle of a procedure or emergency.

    But the NHS won't pay for something like that. They will continue to blame the ward staff for not being able to be 100 places at once. Seriously, Sherree you can just go away. The public will eventually wise up to the fact that a Nurse cannot give one to one care to 15 patients at once even if she is the most compassionate nurse in the world.

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  • I can't remember the exact details of the risk assessment we use, but bed rails are not recommended for some confused patients in some circumstances. Also doesn't the patient have to consent to the use of bed rails?
    A risk of falls doesn't necessarily mean that they are at risk of falling out of bed. What happens if you have bed rails and the patient climbs over them and falls from an even greater height? Perhaps the patient should have been nursed on a lower bed without bed rails.

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  • Fair comments Anna and Anonymous. In my trust, if a patient is at risk of falling then the cotsides are left off and the bed lowered to the ground...they can still tumble out (OK so then they could stand up and fall but....). Some of the wards also have bed alarms and chair far as I can see they just blend into the cacophony of buzzers and pumps when there are only 4 staff on. Having worked in the US also, I wish that we were allowed soft restraints (we have them on the ICU but only mittens with straps and its 1:1 nursing anyhow). I would be interested to know exactly what the changes it just another piece of paperwork to replace the wristband???

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  • Yeah. this cannot be prevented. a wrist band saying at risk from falls doesn't actually do anything.
    what we have to remember is that in other countries these people rightly sedated, but in this country we want to pretend that not only can we do it all, but that these people can be reached, reasoned with or comfortably managed.

    Let's just be realistic and sedate these people, it doesn wear off and we can actually tell if people are dead or not. falling out of bed is a problem but let's face it. These so called caring families are out to get what they can whilst it's patently obvious that prior to admission their involvement is toatally minimal.

    If you want to catch these people out ask them the following questions all the time and everytime.

    1. What is your involvement in your mother/fathers life?

    If it is nothing then discount them as being interested. after all, why wait if it's obvious that their old and might need help.

    2. Where do you live?

    Anything more than 20 miles discounts them as being involved on a practical basis unless they immediately come out and say what it is they do.

    3. Are you involved in looking after your parent(s)?

    If they weren't before and their relative looks like a corpse in a bed then you can discount them as really being involved.

    We all have to remember that children of the elderly pursue things aggressively because of guilt, guilt and guilt. Don't let them bully you. Be honest and tell them about their parents.
    Alot of my older patients are amongst the most rude, selfish and demanding people i have ever met. Particularly as i insist that they wash and dress themselvers, open their bowels and bladders into provided receptacles and not their pants (not all incontinent people lack control) and even worse sit in a chair rather than spending 24 hours in bed.

    In this case, yes a guard rail let down was the issue and that is unfortunate - but that is it. It is unfortunate.

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  • Could not agree more with Anna Lincoln and the others here. There is only so much Nurses can do at the end of the day and Sherre Fagge should be bloody ashamed of herself! She should be standing up for these Nurses and highlighting these issues, not offering her staff up as sacrificial lambs, it's disgusting! And I have to say though Anna, as for the public eventually wising up to the fact that a Nurse cannot give one to one care to 15 patients at once, I wouldn't hold your breath.

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  • Wow Dino your hospital has bed and chair alarms and beds that lower to the ground? My trust can only dream of these things!!

    jjjez, I love you. Your post rocks.

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  • My trust has no dreams. they enjoy a witless, gormless and almost rarified ability to ignore the obvious and are always liable to take the longest and most painful route to failure.

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  • People fall, it's a fact and it is hard when we are short staffed on a ward to monitor everyone all the time. Bed rails can be a risk and should be assessed. Some people are not able to consent. Expectations of relatives need to be realistic and challenged. Our trust have beds which go right down to the floor which can be useful. Sedation can cause falls and a deterioration in respiratory and circulatory functions for people with co-morbidities.

    jjjez - "catch these people out" ...seriously?? Sedate someone and then expect them to pee in an appropriate recepticle? .. mmm may cause a few problems. "Alot of my older patients are amongst the most rude, selfish and demanding people i have ever met" . . . really??? . . What are they asking for "can I use an appropriate recepticle to pee in please as I can't get out of bed because of my restraints" How dare they! Or maybe they have realised that the nurse caring for them doesn't really want them on their ward and they are then responding in kind.

    You do however make some very valid points which unfortunately can be lost in the vitriol in which they are served. I'm not sure if you don't enjoy a little bit of controversy but does your post rock? Nah, it's a bit sad really that you feel the way you do. Having read many of your posts it amazes me that you haven't gone for a career change. Got to be happy at work and it appears to me that you do not like either your job, employers or mostly your customers.

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