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Inquest hears changes made at West Suffolk Hospital following death




The death of a retired horse racing trainer has led to changes at the West Suffolk Hospital, in Bury St Edmunds, an inquest has been told today (May 30).

John Banks, 78, had been admitted to the hospital suffering from a suspected chest infection but suffered a fall on a ward and died following

surgery.

The inquest at Suffolk Coroners Court, in Ipswich, heard that Mr Banks, of Crockfords Road, Newmarket, sustained a fractured hip in the unwitnessed incident in August last year.

He underwent surgery without complications but later Mr Banks' condition deteriorated and he died on September 8 last year.

Mr Banks had suffered a number of previous falls at home but without sustaining serious injury, his GP said in a report.

The fall at the West Suffolk Hospital happened as nurses were changing over from night to day shifts and Mr Banks, who had dementia and other medical issues, was found on the floor close to his bed.

West Suffolk Hospital in Bury St Edmunds. (11470735)
West Suffolk Hospital in Bury St Edmunds. (11470735)

In a statement, ward manager Claire Starie said a full safety assessment had been completed for Mr Banks and there were no indications that he

was at high risk of falls.

She said that ideally a patient with a risk of falls would be placed in a high visibility area but that would not have been possible when Mr Banks was admitted due to the high number of patients who needed supervision that night.

A WanderGuard, which alerts staff if a patient attempts to get out of bed had been requested the following day as Mr Banks appeared confused but one of the devices was not available.

Following Mr Banks death, an investigation into the circumstances surrounding his fall was conducted, Executive Chief Nurse Rowan Procter told the inquest.

The investigation report identified missed opportunities that may have reduced the risk of patient falls and identified that Mr Banks would have

benefited from a WanderGuard.

It also pointed to reduced staff on duty overnight and the need for all patients aged over 65 and at risk of falls to have their blood pressure checked.

On the day of Mr Banks fall, staff were gathered at the nurses station for the night to day shift changeover, said Ms Procter.

Giving evidence, she said changes had been made to ensure the handover was done bay by bay in the ward with patients in view of staff.

Other lessons learned included the need to review the medication being taken by patients admitted with a risk of falls as some had repeat prescriptions and were using medication which was no longer appropriate.

Ms Procter said that despite the changes, it was not possible to entirely prevent falls but the risk could be reduced.

The inquest heard that Mr Banks had died from sepsis, a urinary tract infection and upper intestinal bleeding together with pneumonia.

Mr Banks, known as Jack, was a popular member of Newmarket's racing community, having started work in racing at the age of 15 and become a jockey before achieving his ambition as a successful trainer.

Irene Banks said in a statement: "His death came as an enormous shock as I expected him to come home after a couple of day."

Mrs Banks, who was married for 29 years added: "He was a very kind man who lived life to the full."

Senior Suffolk Coroner Nigel Parsley, in a narrative conclusion, said: "John Banks died from a natural disease contributed to by injuries received in an earlier fall."

After the inquest, the Bury Free Press approached West Suffolk Hospital for comment and Ms Procter said: “Our thoughts are with Mr Banks family and we offer them our sincere condolences.

"We are very sorry that he sustained an injury whilst in our care and we carried out a thorough investigation to ensure we understand and learn from what happened to him."

“The Trust strives to provide an excellent quality of care and experience to every patient and we have made changes to our practices as a result of the investigation to help us improve the care we provide.

“Preventing falls is an issue for many hospitals. We do not infringe on a patient’s liberty to stand up and walk around, and they have the right to get out of bed if they want to and it is in their best interests to mobilise to their full potential.”



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