Hospital takes action after immobile Shropshire pensioner discharged home with no care package died alone
A hospital trust says it has addressed many of the concerns highlighted by a coroner after a Shropshire pensioner died without a care package being activated.
Samuel Joseph Brookes, of Highley Park Homes in Netherton, near Bridgnorth, was found dead on April 22, 2024 by his grandson.
It is unknown when the 84-year-old died, having been discharged from Russells Hall Hospital in Dudley two weeks earlier.
An inquest into his death concluded earlier this year that Mr Brookes died following neglect to provide him his required care.
John Ellery, senior coroner for Shropshire, Telford and Wrekin, subsequently produced a 'prevention of future deaths' report highlighting his concerns.
He explained that Mr Brookes had been admitted to hospital following a fall and a long lie at home. The hospital arranged his transportation without rearranging his required care (two carers, four times a day).
Mr Brookes, who was immobile and lived alone, was transported to his bed, where he could not reach his pendant alarm or mobile phone, which was in another room. He was then left unattended for two weeks until he was found by his grandson, unresponsive and wedged between his bed and bedroom wall.
An ambulance was called, but on arrival paramedics confirmed Mr Brookes was deceased. He had died at some time between April 8 and April 22.
Mr Ellery said there is a risk that future deaths will occur unless action is taken. His concerns were:
The hospital arranged for Mr Brookes' transportation home without rearranging the required care.
There was no record, documentation or process to show or demonstrate that the care had been rearranged.
The transport company was responsible for transportation only and was not required to notify either the hospital or, if known, the care company of Mr Brookes’ safe return. It proceeded on the basis or assumption that care would have restarted within four hours or sooner.
Mr Brookes did not have his alarm pendant around his neck and nor was his mobile phone available (it was in another room). Accordingly when Mr Brookes got into difficulty he could not raise the alarm or call for help.
In response, Diane Wake, group chief executive at The Dudley Group NHS Foundation Trust, said an immediate cross-divisional and multidisciplinary team approach has been developed to devise a robust improvement plan.
“Many of the actions have been implemented immediately with the remaining actions progressing within agreed timeframes,” she said.
“Some of the actions identified regarding patient transport fall out of scope of the trust. These will be taken forward by our deputy chief operating officer and head of site operations and discussed with relevant integrated care system partners in relation to contractual obligations for ensuring patients discharged home are safe and have access to the agreed methods of communication e.g. mobile telephone, pendant alarm (should they have or require one).
“In addition to our improvement plan, the trust has re-established with a renewed and enhanced focus the Discharge Improvement Group.
“This group has strategic organisational objectives focused not only on increasing the timeliness of patient discharges from the organisation, but more importantly on ensuring that each discharge is carried out with the highest standards of safety and quality.
“As part of this work, dedicated workstreams have been initiated to support the proactive and coordinated planning of discharges across both simple and complex care pathways.
“The group have reviewed and agreed clear outcome measures to ensure the impact of actions can be measured, and that they are having a positive impact. Metrics to monitor safe discharge will include readmission rates, patient and carer satisfaction scores, the percentage of patients returning to their original place of residence, safeguarding concerns and the number of failed/incomplete discharges.”
Ms Wake added that a thematic review of historical discharge-related incidents is underway to identify key learning points and inform future priorities.
“The group comprises of multidisciplinary representation, including colleagues from within the acute trust, our health and social care partners, the local authority, and a representative from our patient community.
“This collaborative approach is intended to provide confidence that discharge processes are being strengthened system-wide, with patient safety and continuity of care as central principles.”
