Expert Lawyers Call For Lessons To Be Learnt Throughout NHS
The family of a grandfather-of-six, who died after falling from a hospital window, have welcomed confirmation from the hospital Trust that improvements to protecting patient safety have been made.
Bob Thompstone died on 3 December 2012 after being admitted to Basingstoke Hospital in a confused state three days earlier.
The 76-year-old went missing from the ward on two occasions throughout the night before his death.
Following a two-day inquest at Alton Magistrates Court which ended today (23 January) HM Coroner Andrew Bradley recorded a narrative verdict.
He said: “He (Mr Thompstone) was discovered wandering in the hospital in the night in a confused state on two occasions and then went missing on the third occasion. He was found deceased on the roof of the canteen on the morning of 3rd December 2012 having fallen from an upper window of the hospital.”
Expert lawyers at Irwin Mitchell instructed by Mrs Thompstone have been informed of the findings of a full investigation conducted by Hampshire Hospitals NHS Foundation Trust into the incident, which found there were areas where ‘the care provided to Mr Thompstone was not of the standard the Trust would wish to give or that he was entitled to expect.’
The internal investigation also found that risk assessments should have been carried out on the two occasions he went missing before his death. If these had been carried out, the review stated the outcome is likely to have been that Bob needed one-to-one care and supervision which would have prevented him wandering off the ward for the third and final time.
The Trust also confirmed in the review that action has been taken to improve systems in a number of areas including:
- Mental Health referral forms and Psychiatric referral forms being properly completed where necessary throughout the patient’s stay in hospital;
- Raising the profile of mental health issues throughout the Trust by employing more suitably qualified staff;
- Increasing audits on the maintenance of windows;
- Permanent night duty for staff should cease to support up to date learning;
- Introducing and training staff on new policies on ‘Missing Persons’ and ‘Managing a safe environment for the patient in a confused state’.
Speaking on the family’s behalf, Elizabeth Marchant, a medical law expert at Irwin Mitchell’s London office, said: “This is a tragic case that has left a family devastated by the loss of a loving husband, father and grandfather.
Expert OpinionThis is a tragic case that has left a family devastated by the loss of a loving husband, father and grandfather.
“They would like to take this opportunity to thank the Coroner for taking the time to investigate the reasons for their loss and are grateful to have received answers to the many questions they had about the events leading to Bob’s death.
“Events such as these should not happen under any circumstances and we whilst we appreciate the Trust taking action and confirming lessons have been learnt, we expect these lessons to have been shared transparently throughout the NHS. This open approach is the only way to protect the safety of patients and prevent the same tragedy from happening again.”
Elizabeth Paterson (née Marchant) - Solicitor
Mr Thompstone’s family have said that they welcome the Trust’s internal review and the action plan drawn up to prevent a similar incident from occurring again. Mrs Thompstone, from Selbourne, added: “We just hope that Bob’s death was not completely in vain and that it has been shared across the NHS to improve care and safety for people in a similar situation that he faced.”
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