Prevention of Future Deaths report: Hazel Wiltshire (1 September 2021)

This is shocking but sadly not unique. I am extremely sorry for the patients that were crying out for assistance but I feel even deeper sympathy for the nurses in that environment. Understaffed and struggling with the overwhelming demands I am sure those nurses were every bit as devastated about this patients fall and subsequent death as the coroner and yet battled on to attempt to provide some care even though they would have known it was less than adequate. Staffing solutions, recruitment and strategies are often in the hands of people who have not walked where these nurses have and therefore don't know that pain. All solutions need to come from the people who actually know what the problems are and innovative ways forward can be created together. I agree it did appear there was a systemic problem that required action but ward level leadership to create better staffing numbers and allow timely responses to patients needs should be the starting point. I feel particularly sorry for the matron giving evidence, who was looking after and guiding her? what training and support had she been given and how many people's jobs was she doing? Nurse to bed ratio recommendations are helpful but when nursing numbers are at a minimum, senior management can resort to  just moving staff around to make the numbers even with no consideration given to acuity or dependency in the areas they move staff from. This can result in long delays for patients who require assistance getting the help they need. Matrons and ward managers are therefore left powerless to improve their own ward as a successful ward will constantly be left short to support other less well managed areas. There are solutions  but we have to work and stand together to create them.

Thank you for your comment. It’s a dreadful and upsetting set of circumstances. My husband was recently in hospital and the experience of calls being unattended was routine.
 

This was clearly devastating for the patient, her family and all involved.  It reinforces the need for a safety systems approach and sufficient resources to ensure that risks are assessed and managed. There are 50k nursing vacancies in the NHS, this comes with significant safety consequences. I strongly agree with your point of the need to prioritise for acuity and dependency, clearly a huge challenge for the service at the moment. 

This patient broke her hip, blackened her eyes and was completely bruised through this incident.  This was not the only issues caused by staff - she was put into a covid ward when she had been isolating at home for over 18 months, she caught covid at the hospital, she broke her hip at the hospital, she was given medicine that she was allergic to at the hospital, they also managed to lose her glasses and change her ward repeatedly.  The toilet incident happened as she was terrified of the nurse shouting at her the way she had witnessed the nurse do to a patient the day before.