A coroner has raised concerns after a patient fell and died at Chesterfield Royal Hospital.
Lollipop lady Cheryl Lunn, 56, suffered a significant head injury when she fell from her chair on Ridgeway ward on Monday, February 16.
Mrs Lunn died the following day as a result of acute subdural haematoma – a serious condition where blood collects between the skull and the surface of the brain.
At Mrs Lunn’s inquest on Monday, coroner James Newman said he was concerned that she was not given Warfarin – a medicine used to slow down the blood-clotting process – following the fall.
He also voiced concern that Mrs Lunn waited 18 hours for a second CT scan despite a deterioration in her condition.
Hospital chiefs have apologised to Mrs Lunn’s family and promised to review protocol following the tragedy.
Mrs Lunn, of Pullman Close, Staveley, was admitted to the Calow hospital in January, Chesterfield coroners’ court heard.
While on the ward, she suffered a number of falls because of various medical complications, including low blood pressure.
The court heard Mrs Lunn’s physical condition appeared to improve – but then she suffered the fatal fall.
Mr Newman said: “Following a thrombus in October 2014, Mrs Lunn was started on Warfarin. At the time of the fall on February 16 and the first CT scan, her Warfarin was stopped and she was placed under regular neurological observation.
“Despite a clear deterioration in her neurological condition, it was not until some 18 hours later that a second CT scan was performed and Warfarin again commenced. At this time she was not considered suitable for neurosurgical intervention.
“I find that there were at least two missed opportunities – firstly, to commence full Warferin reversal; secondly, to advance Mrs Lunn for a repeat CT scan earlier despite clear neurological deterioration.”
But Mr Newman stressed: “I have no evidence to say these would have made a medical difference.”
Mr Newman recorded a narrative verdict setting out the facts.
After the inquest, Lynn Andrews, director of nursing and patient care at Chesterfield Royal Hospital, said: “We would wish to pass on our sincere condolences to Mrs Lunn’s family on their recent bereavement and are sorry that the care we gave was unable to prevent her from falling again while in hospital, causing her to develop a significant brain injury.
“Mrs Lunn was in hospital to investigate repeated falls at home and was correctly assessed as ‘high-risk’ when she was admitted to the ward due to a number of medical conditions and complications. The ward team provided appropriate falls prevention care and additional nursing supervision but sadly she fell from a sitting position in a chair.
“The coroner has reflected on the timing of clinical decisions made after Mrs Lunn had fallen. We will address these concerns by reviewing the protocols we follow when a patient has sustained a fall and requires neurological observation. And although the coroner noted there was no evidence to suggest a different outcome may have been possible, we want to assure Mrs Lunn’s family we will make sure we improve how we care for these ‘at-risk’ patients.”