An elderly man fell and died after he was left unattended in a sick bay at a London hospital in breach of policy.
Ian Hegarty, 89, was first admitted to hospital on June 5 this year after falling at home.
He was transferred to the Royal London Hospital in Whitechapel on June 14 for management of his underlying health conditions. Hospital staff assessed him to be at a moderate risk of falls.
The ward put mitigation measures in place to address the risk of a fall, according to a Prevention of Future Deaths report issued by Assistant Coroner for Inner North London Ian Potter.
This included being placed in a bay where all four patients were constantly within the sight of an allocated member of staff who was expected to remain in the bay at all times.
On June 16, the allocated member of staff left the bay. During this time, Mr Hegarty had an unwitnessed fall, causing him to sustain a fracture to his right femur.
Shortly after the fall, Mr Hegarty’s blood pressure dropped and his clinical condition deteriorated. He died in the early hours of June 17.
Mr Potter wrote that, by leaving him unattended, the member of staff “did not follow the protocol that had been put in place to reduce the risk of falls for all patients in that bay”.
He added that “the plan of care put in place specifically to reduce the risk of falls for multiple patients was not followed”.
“I heard evidence that an internal investigation into the matter has been commenced but is not yet concluded. As such, there was insufficient reassurance, at the time of the inquest, that the risk is being addressed,” he wrote.
A spokesperson for Barts Heath NHS Trust, which operates the Royal London, said: “We express our condolences to the family of Mr Hegarty. Our internal investigation is continuing, however we have already implemented changes to prevent further harm to patients.”
The Trust has until December 9 to respond to the report.
