Ex-Shrewsbury tennis coach's death 'avoidable'
The death of a former England tennis coach from Shrewsbury who died after falling while in hospital could have been avoided, an inquest jury has ruled.
John Crooke, 84, of Oakfield Drive, Copthorne, was taken to Ludlow Community Hospital last Christmas Eve after falling a number of times at his home.
He fell from bed on December 28, hitting his head, and was transferred to the Royal Shrewsbury Hospital where he died on January 6.
The jury in the two-day inquest, which ended on Wednesday, ruled that a "more appropriate level of supervision" from staff and a working bed alarm might have prevented the death.
The inquest at Shrewsbury Town Football Club heard Mr Crooke, who had been national head coach for England and Wales, had developed dementia in the last year of his life.
The jury of four women and six men were told Mr Crooke was admitted to Ludlow Hospital at 5.15am on December 24 after falling from bed and to give his wife and family respite care over the holiday period.
He fell again on December 28, when he hit his head and was transferred to the Royal Shrewsbury Hospital, where he died on January 6.
On the first day of the hearing Teresa Smith, a nurse at Ludlow, said Mr Crooke was in the bed closest to the nurses' station and had initially been placed on one-to-one supervision.
A bed alarm had been installed under the sheets, which would alert nurses whenever Mr Crooke got out.
"The alarm is tested each time someone gets into bed," said Mrs Smith. "On his arrival at hospital Mr Crooke was agitated and upset. We moved him close to the nurses' station so we could supervise him.
"Over the next few days he calmed down. On the day he got out and fell, the bed alarm failed to go off.
"On inspection, the wires had been stretched and this could have been done by the patient moving on the bed and pulling on the wires."
The verdict from the jury said: "It is probable that had there been a more appropriate level of supervision and the bed alarm functioned as expected, the fall leading to the death of Mr Crooke could have been avoided."
Tessa Norris, director of operations at Shropshire Community Health NHS Trust, said: "Our thoughts are with Mr Crooke's family at this difficult time.
"Following this incident and subsequent learning investigation, we have implemented a number of improvements which include extra checks to ensure that pressure alarm pads are working fully and supporting staff with new and clearer guidance in patient observations."
