Nurses apparently ignored the cries for help of a frail, elderly patient who subsequently fell and died four days later in a Fife hospital.
Two charge nurses sat at a nursing station only a few feet from the door of 84-year-old Christina Dougall’s room in Queen Margaret Hospital as she repeatedly shouted for assistance to go to the toilet. When another nurse, who had been busy, went to her aid minutes later she found her lying on the floor beside urine and faeces.
A fatal accident inquiry in Dunfermline also heard the patient was considered disruptive and the door to her room had been closed.
Mrs Dougall’s arm was fractured in her fall on July 11, 2009, and she died of a heart attack in the Dunfermline hospital on July 15, 2009.
A judge ruled there was no evidence to connect the injury to Mrs Dougall’s death but he described “shortcomings” in her care, which were admitted by Fife Health Board.
In his report of a fatal accident inquiry in Dunfermline, Sheriff Ian Dunbar said, “I find it slightly puzzling that two senior nurses should sit close to the source of these calls and, apparently, ignore them.
“One of them had been in the room and had done nothing to get help for the toilet if that is indeed what she wanted.”
Although a post-mortem listed her fractured humerus as a contributory factor to Mrs Dougall’s death, Sheriff Dunbar concluded Mrs Dougall’s death was not caused by an accident.
Due to heart problems it was stated that she was at risk of suffering a heart attack at any time. The sheriff also found her death could not have been prevented by any reasonable precautions and that there were no defects in working systems which contributed to the death.
However, he said, “While there is no causal connection between the fall and the death I feel it is important to lay out the evidence as given if only to serve as a reminder to all about what happened or what was done or not done.
“There has been a full inquiry conducted by Fife Health Board and there have been disciplinary proceedings.”
Sheriff Dunlop regretted being unable to ease the frustration of Mrs Dougall’s family, who he suspected would still have unanswered questions about her care.
The inquiry heard Mrs Dougall, who was admitted for back pain, had been shifted to a side room as she was disturbing other elderly patients in ward five. Staff found her demanding and she was said to buzz frequently or bang a cup or glass for attention.
Just before her fall, witnesses in the inquiry said the door to her room had been closed and her curtain drawn. One claimed she saw nurse William MacAulay pull the door shut and turn off Mrs Dougall’s buzzer, but he was insistent he did neither.
He and nurse Elaine Hammon admitted being at the nursing station as Mrs Dougall called for assistance but they said they were undertaking other tasks and that others, including Mr MacAulay, had already been to her room.
A spokesperson for NHS Fife said, “We would like to express our sympathy to the family of the late Mrs Dougall. We welcome and have noted the detail of the sheriff’s determination and have already used this to review practices and procedures within the hospital, where appropriate.
“We have also noted comments made about actions of our staff and these have been used to inform our staff training programme.”