An elderly Sheffield man who died of a brain injury had 12 falls while under hospital care, an inquest heard.
Irvine Simmonds, aged 88, of St Michael’s Crescent, Ecclesfield, was admitted to surgery on September 3 after breaking his hip in a fall in his home.
Mr Simmonds, who lived alone and was described by his family as ‘independent’, had passed a medical three days before the fall.
But he suffered a brain injury which led to his death from pneumonia in the Hallamshire Hospital on November 3.
The inquest heard Mr Simmonds had six falls at the Northern General Hospital in September 2014
Coroner Chris Dorries asked Matron Diane Fawbert: “Not every fall has been recorded. It’s a little bit hit and miss wouldn’t you say?”
Matron Fawbert replied: “Yes, yes it is.”
After a final fall on September 25, Mr Simmonds was deemed fit to be transferred to Beech Hill Rehabilitation Centre in Norfolk Park despite ‘discussions’ about one to one care.
Mr Dorries said Beech Hill felt they ‘couldn’t handle him’ and staff ‘expressed concerns’ if he was suitable for the rehab ward.
Linda Brown, a pathways manager, said the transfer had ‘not a gone as she had hoped’ and it was revealed Beech Hill did not have a full picture of the fall record but did bring themselves up do date quickly.
Mr Simmonds had two further falls in the centre and was transferred back to Northern General on September 30 after showing increasing signs of confusion and suffered a further four falls.
Dr David da Costa, a brain consultant at Northern General Hospital, said results from a CT scan on October 1 revealed a bleed on the brain but said the carpet fall did not cause the injury.
Mr Dorries, who recorded a narrative verdict, said: “The most striking feature of this case is that Mr Simmonds suffered a great many falls between his admission to hospital and his death two months later.
“Twelve falls in a space of six weeks seems a significant number to say the least.”
The coroner said ‘four or five falls’ leading up to the October 1 CT scan had ‘more likely than not’ caused the original bleed after which events deteriorated.
Mr Dorries said the hospital trust had outlined measures to prevent the same situation happening again.
He added that Mr Simmonds was examined properly after every fall even with no apparent injury and conceded it was ‘difficult’ to observe patients at all times.