A sheriff has listed a catalogue of faults found within NHS Fife in his findings into the death of a Fife pensioner who fell at Queen Margaret Hospital, Dunfermline, in late 2005 and died three days later.
The fatal accident inquiry into the death of Mary Forrest (85), found that she died on December 29, 2005, and that the accident which contributed to her demise happened at 4.50pm on December 26, 2005, in ward eight of the hospital.
Sheriff Ian Dunbar has stated that the cause of her death was atherosclerotic coronary heart disease and cranio cerebral injuries.
He said that the cause of her fall was unknown but criticised many factors which were highlighted during the inquiry, which was heard at Dunfermline Sheriff Court.
Mrs Forrest was being treated for a lack of sodium and her family warned hospital staff when she was admitted that she was confused and unsteady on her feet.
She took ill over Christmas 2005 and was taken to hospital on Boxing Day.
Her family were told that she would be out in a couple of days but her condition worsened and she was then admitted to the intensive care unit of the hospital.
A CT scan showed she had sustained a fractured skull and there was bleeding in her brain.
Among his findings, Sheriff Dunbar said:Steps should have been taken to ensure that prescribed intravenous fluids were delivered. There was insufficient regard paid to Mrs Forrest’s unsteadiness and the fact that she was transferred to a bed by a slide. There was a failure to ensure delivery of prescribed intravenous fluids. There was a failure to act to replace the removed canula. There was a failure to note or document all or any incidents which had occurred and involved Mrs Forrest wandering or being off the ward. There was a failure to communicate any such incidents to medical staff. There was a failure to ensure the ward was adequately staffed. There was a failure to understand and implement the procedures for obtaining additional staff when a ward was short-staffed. There was a failure of communication between nurses and also between nurses on the one part and doctors on the other.As a result, Sheriff Dunbar said that there should be defined rules or guidelines for nurse co-ordinators and compulsory training for them.More training compulsoryHe also feels that more training on procedures including risk assessment, observation and documentation should be compulsory.
He also states that the training of doctors and nurses in areas such as risk assessment, communication, documentation and observation should be more co-ordinated.
Sheriff Dunbar said that Mrs Forrest’s family will feel she was “let down” at various times and in “various” ways during her stay in Queen Margaret Hospital.
He said, “Whether or not she was let down, and, if she was, whether or not any of it contributed to her death remains a question that this inquiry has not been able to fully answer.
“One of the few positive things to come out of this inquiry is that NHS Fife has apparently taken a long and detailed look at procedures and practices and taken some steps to try to ensure that a similar situation does not arise again only time will tell.”
He added, “It is also important to acknowledge that NHS Fife took steps at a relatively early date to write to the family, accepting that their care of Mrs Forrest was not what it might have been.
“However, I have to wonder if the inquiry may not have been better served if some of the people who actually did the work had also given evidence.”
Albert Chinyamuchiko had told the inquiry that he worked on ward eight at the time and was looking after another patient when he turned around and saw Mrs Forrest collapse.
It was the second such fall she had suffered that he was aware of.Chief executive’s apologyMrs Rosemary Forrest, daughter-in-law of the late Mrs Forrest, had told the inquiry that the 85-year-old had been “independent and very mobile” prior to her hospitalisation.
The inquiry had heard that the family made a formal complaint to NHS Fife and received a letter of apology from chief executive John Wilson.
Mrs Forrest had said, “I do actually blame the hospital staff, both the nurses and the medical doctors, for being negligent in her care.
“They did not carry out their duty of care during her stay in ward eight.”
She added, “I do feel guilty, because I thought if I had never taken her to the outpatients department that day she would still be alive and that is a given fact.”
Sheriff Dunbar slammed the length of time the inquiry took.
He said, “The delay is a disgrace and reflects badly on the whole system.
“One of the consequences of the very long time between the incident and the inquiry has been that the memories of witnesses have not been as clear as they might have been.”
He added, “As it is, not only will the Forrest family feel it has been let down by the system of health care, it will also feel it has been let down by the legal system and, insofar as I can do so, I apologise to them for that.”
A spokesperson for NHS Fife said that the health authority would be looking at the sheriff’s findings before deciding what action, if any, to take.