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

    • UK
    • Reports and articles
    • Pre-existing
    • Original author
    • No
    • Jonathan Landau
    • 01/09/21
    • Health and care staff, Patient safety leads


    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.

    Coroner's concerns:

    1. 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.
    2. 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.
    3. 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. 
    Prevention of Future Deaths report: Hazel Wiltshire (1 September 2021) https://www.judiciary.uk/publications/hazel-wiltshire-prevention-of-future-deaths-report/
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    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.

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    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. 

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