Pensioner died following strike action at Norwich hospital

Conditions during Teresa Symonds’ stay at the Norfolk and Norwich Hospital (N&N) last year saw "sub-optimal staffing levels" and paperwork only partially completed and incorrect. 

The details of her admission were revealed at an inquest into her death held at Norfolk Coroner’s Court this week. 

The retired home care assistant, who lived in Bracon Ash, near Wymondham, was taken to hospital with confusion on May 26, following a fall at home a month prior. 

While there, she suffered two further falls with the latter causing a severe brain injury from which she died on November 6. 

A Root Cause Analysis by the N&N was carried out following both incidents and sections from the final investigation report were read out in court. 

It said: “With regards to the second fall on June 15, the fall occurred when she fell backwards and sustained a head injury. 

“The incident occurred during the junior doctors’ strikes and at a very busy time of day on the ward. 

“As the consultant was providing medical cover for the wards, there was a delay in the consultant being able to attend her ward. 

“Working condition factors were stated to be sub-optimal staffing levels on the ward. 

“Four health care assistants were on shift rather than the normal establishment of eight and this doesn’t take into account the extra staff required to provide one-to-one care.  

“One-to-one supervision to all the patients who would benefit from enhanced supervision was unable to be provided.” 

The report revealed that a falls assessment was not completed until day four of her admission, and inaccuracies failed to show her history of falls. 

Subsequent risk assessments continued to contain incorrect information and were sometimes only partially completed. 

A ‘Think Yellow’ initiative – in which patients who are at a particular risk of falling are given special yellow socks to make it easier for staff to identify them - should have been applied but had also been delayed. 

She was eventually admitted to Trees nursing home in Harleston, south Norfolk, on July 20, and died there three months later. 

Her son, Richard Symonds, attended the inquest at County Hall, Norwich, on April 29. 

He said: “Before going into hospital, mum had been able to look after herself and needed no assistance for anything. 

“After her second fall [at the hospital], everything changed. 

“She struggled to know who even family members were. 

“It is the feeling of the family that if mum hadn’t suffered such catastrophic injuries when she fell, she would be at home now.” 

Her primary medical cause of death was given as traumatic subarachnoid haemorrhage due to a fall. 

Senior coroner, Jacqueline Lake, said: “As the cause of death relates back to the fall and in view of the history, I am satisfied that this was the cause of her death 

“This was an unintended act with an unintended outcome.” 

She concluded Mrs Symonds's death was accidental. 

She added: “The investigation carried out by the hospital has shown that all records required to be completed were not and there were some discrepancies within the documents that were completed. 

"A review has been undertaken, and that has been accepted the hospital who has taken action with a view to prevention of future deaths.” 

The N&N has since shared lessons learned from the incident citing the importance of accurately completing risk assessments. 

Its clinical educator is also providing additional teaching sessions regarding risk assessments and care plans.  

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