Falls policy reviewed at Royal Shrewsbury Hospital after man fell twice while there before death

John Patrick Squires, 80, from Longnor near Shrewsbury, died in hospital on April 2 this year, having been admitted to hospital after falling at his home in March.

Assistant coroner for Shropshire, Joanne Lees, was told that Mr Squires had a fall in the hospital on March 16 and a second one on March 19. She said the second fall aggravated the internal bleed that he was in hospital for and he passed away on April 2.

The inquest heard that because Mr Squires had been deemed at risk of fall, he was in a special "high-low" bed that should have had the side rails down and crash mats around the bed.

At the time of the second fall evidence showed that the side rails were up and the crash mats had been removed.

"It appears Mr Squires had manoeuvred to the gap between the side and bottom rail and got out of bed," Mrs Lees said.

Matron Kerry Thompson told the inquest that there had been a yellow sticker over Mr Squire's bed alerting staff that he was of medium or high risk of a fall. Staff should have then checked his notes to look as his risk assessment, she said.

The locum staff had not been award of what Mr Squire's risks were.

She said that following Mr Squires' death there had been a review at the hospital of its policy over falls.

Mrs Lees suggested that the yellow sign should include on it what action should be taken as asked Matron Thompson to take that suggestion back for discussion at the hospital.

"I can not say whether that would have made a difference, risks can not be eliminated completely," the assistant coroner said.

Mr Squires family said the 80-year-old had been a very active man who loved his dog and his gardening and had been the life and soul of the family.

They said that after his second fall in hospital there had been a huge deterioration in his health.

The assistant coroner recorded that Mr Squires' death that been an accident.