NEW policies on preventing and dealing with falls in hospitals, and quarterly training sessions on the subject, have been introduced in hospitals by Gwent's health board following the death of a patient last year.
Richard Barry Thomas - known as Barry - died at Ysbyty Ystrad Fawr, Ystrad Mynach in January 2018.
An inquest was told that his family raised concerns about his care, prompting Aneurin Bevan University Health Board to conduct an investigation.
The 78-year-old had been active and a keen walker, and senior coroner for Gwent Caroline Saunders was told he had been admitted to Ysbyty Ystrad Fawr in November 2017, following a fall at home.
In witness statements from hospital staff told how Mr Thomas had a history of falls.
At the hospital, he was assessed by staff, who believed him to have Parkinsons disease. He was discharged on December 6, but fell a week later and was re-admitted to hospital.
He left hospital for a few hours to be with family on Christmas Day, but fell twice in hospital that night - on one occasion injuring his head.
The coroner heard Mr Thomas' condition deteriorated and, on January 2, a CT scan was performed, which showed inoperable bleeding on his brain.
Mr Thomas' condition deteriorated further, and he died on January 8.
A post mortem examination recorded the cause of death as bronchopneumonia.
Penny Gordon, who compiled the health board's report on Mr Thomas' care, was asked by Ms Saunders about the policy for dealing with patients who fell.
Ms Gordon said the investigation found a CT scan should have been performed on Mr Thomas earlier, owing to his head injury on December 25.
Mr Thomas was instead observed by staff, who measured his responsiveness on the Glasgow Coma Scale for head injuries. But Mr Thomas became agitated and restless in the days that followed.
Ms Saunders asked again if a CT scan should have been performed at that stage. Ms Gordon agreed that it should have been, given that the family had raised concerns about Mr Thomas' changed condition.
She told Ms Saunders that not enough attention had been paid to Mr Thomas' family at that time - bt if a CT scan had been performed earlier, Ms Gordon said, the conclusion was that it would have been unlikely to affect the outcome.
Ms Gordon said that since Mr Thomas' death, new policies had been introduced in the hospital, and the falls policy was now displayed in wards. Mr Thomas' case had been shared across the health board, and hospital staff now attended fall training sessions every three months.
Ms Saunders said neither of Mr Thomas' falls on December 25 had led to a new risk assessment of his condition.
Notwithstanding the fact Mr Thomas had Parkinsons disease, she said, his death would not have occurred at that time if he had not fallen.
Coroner's conclusion: Accident.
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