St Albans man’s inquest sparks Coroner’s concerns about health services

PUBLISHED: 05:55 14 May 2015

Herts Coroner's Court

Herts Coroner's Court

Archant

A coroner has hit out at the ‘daft’ fragmentation of health services which is making it difficult to investigate deaths at an inquest into an elderly St Albans man.

Herts Coroner Edward Thomas criticised the bureaucratic hurdles facing his department’s investigation into deaths at the inquest held last week of Raymond Woolston, of Watling Street, St Albans, who died at Watford Hospital on July 25 last year.

Mr Woolston, 89, had undergone two operations to mend his fractured hip and upper leg after separate falls.

Sepsis set in after the second operation, and Mr Woolston suffered multiple-organ failure.

Speaking to witnesses - including the orthopaedic surgeon who operated on the octogenarian - representing West Herts Hospitals NHS Trust (WHHT) and Herts Community NHS Trust (HCT), Mr Thomas blamed the court’s difficulties in finding the correct people for information on ‘daft’ changes to health services.

He said: “I thought the government said it wasn’t going to have any further reorganisation.”

After an initial straightforward operation for a hip fracture which occurred after a fall at home, Mr Woolston was transferred from Watford for rehabilitation at Hemel Hempstead Hospital.

He fell shortly after arriving there. An agency nurse was unable to reach him in time when he stood up which resulted in a more complex fracture.

The court heard that while the majority of hospital’s wards were under WHHT, St Peter’s ward, to which Mr Woolston was discharged, was the responsibility of HCT.

Addressing Trudy Reynolds, clinical services manager for the latter organisation, Mr Thomas said: “It is difficult to know who to contact for reports now; it is very complex for us.”

He was also concerned that hospital staff were stretched and under “immense pressure” to cope with additional patients, particularly those considered “bed blockers”.

Ms Reynolds explained that some patients remained in the hospital for some time as “they may not quite be ready to go home, because there is a delay in their social [care] package”.

Mr Thomas asked: “They are bed blockers?” to which Ms Reynolds replied: “Sadly yes.”

When she confirmed that the care packages were the county council’s responsibility, Mr Thomas said: “It is going to cause a real problem in the next few years - no-one is really grappling it at all.”

Concerned that nurses were spread across the hospital site “having to deal with more than normal” Mr Thomas asked whether this contributed to Mr Woolston’s fall.

But Ms Reynolds replied: “It didn’t as staff were there.”

She explained that patients on St Peter’s ward had a special sensor mat placed under them, which set off an alarm to alert nursing staff.

Ms Reynolds added: “When he stood up, the sensor mat alarmed, the nurse turned and rushed to him.”

Since his death the ward has changed its alarm system, so when patients move the sensor sets off a voice-activated recording, of someone they know, asking them not to stand up until a nurse is with them.

A post mortem showed Mr Woolston died of sepsis as a result of wound infections in his left hip and leg. Secondary causes were cardiac failure, ischaemic (coronary) heart disease and a fractured neck femur (operated).

Mr Thomas said: “Wound infection is a known complication. There was a danger of infection.

“He died from a recognisable complication of a necessary operative procedure appropriately carried out. Nothing went wrong with the procedure.”


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