A coroner criticized a north London NHS trust for significant communication failures that contributed to the death of Carl Eastman, a 96-year-old patient, from an unwitnessed fall. Eastman, who was under care in the Royal Free Hospital, had multiple prior falls before he sustained a fatal injury due to inadequate supervision. The coroner found numerous deficiencies in record-keeping and staff communication, warning that without significant changes, the risk of similar incidents could persist. Although the trust implemented measures to address post-fall procedures, broader skills deficits were suggested as a concern.
Assistant coroner Ian Potter highlighted that Mr. Eastman suffered an irreversible brain bleed due to inadequate observation and communication failures in his care.
The coroner noted systematic deficiencies in record-keeping and communication, leading to a significant risk of future incidents unless addressed comprehensively.
Despite measures being implemented by the trust to rectify post-fall procedures, concerns remain that the deficiencies may indicate broader issues with staff skills and knowledge.
A member of staff's failure to report Mr. Eastman's previous falls contributed to the lack of necessary medical review, highlighting flaws in hospital communication protocols.
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