On 24 March 2021, an investigation into the death of Hazel Fleur Wiltshire was opened. The conclusion of the inquest was that Mrs Wiltshire died from pneumonia caused by a fall and by COVID-19 that she acquired in hospital. The fall was caused by her trying to relieve herself without assistance in the context of long delays in answering calls bells at the time.
Mrs Hazel Fleur Wiltshire was admitted to the Princess Royal University Hospital on 14 January 2021 following a fall at home. Although she had a number of factors indicating a risk of further falls, no risk assessments were completed on three wards and there was no evidence that measures that could mitigate the risk of falls were considered.
Mrs Wiltshire's toileting care plan indicated that she was to be assisted with her toileting needs and she had access to a call bell. However, there were lengthy delays in responding to the call bell and on the night of 22 January 2021 she tried to relive herself without assistance which caused her to fall. She died in hospital on 19 February 2021 from pneumonia caused by the fall and by Covid 19 that she acquired in hospital.
- The matron who gave evidence was not aware of obtaining data on response times from the call bell system and had not introduced any other system to monitor response times.
- Staffing levels were inadequate due to higher dependency of patients with Covid. I heard that one patient had to soil herself in her hand as no one was available to assist her with her toileting needs. Mrs Wiltshire phoned home on occasion to ask her family to call the ward because they were not responding to her call bell. The family could hear other patients on the ward crying out for help.
- Although Mrs Wiltshire was at risk of falls, no risk assessments were completed on any of the three wards in which she stayed. This suggests a systemic problem across the hospital that requires remedial action.