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Maidstone and Tunbridge Wells NHS Foundation Trust has apologised after staff shortages led to the death of an elderly patient who fell off a hospital trolley.
Katherine Hogan, 93, had been left overnight on a trolley in a clinical decision unit at Maidstone Hospital because of staff shortages.
She fell off the trolley and suffered head injuries that led to her death 15 days later on August 31, 2019.
An inquest that concluded last July determined that Mrs Hogan had "sustained a severe head injury and major haemorrhage due to a high impact fall from a trolley".
But the coroner Sonia Hayes noted that Mrs Hogan had been left in an area that "was not suitable to keep a patient overnight".
She said: "Staff shortages contributed to the patient being left in the clinical decisions area of the unit on a trolley and those staff shortages had been reported to those responsible for the hospital."
The coroner told the hospital trust: "The inquest revealed matters giving rise to concern.
'There is a risk that future deaths could occur...'
"In my opinion there is a risk that future deaths could occur unless action is taken."
The coroner issued a Regulation 28 report to the health trust, requiring it to report within 56 days what action in had taken to rectify matters and prevent future deaths.
The trust responded on January 11, the last day permitted for a response.
The trust's chief executive Miles Scott said: "First and foremost, I have written separately to the family of Mrs Hogan to offer my sincere condolences.
"The trust carried out an internal investigation as regards the circumstances leading to the fall sustained by Mrs Hogan which was provided to the inquest.
"As part of the trust’s continued objective to learn and improve, this internal review was recently re-opened with the investigation scope further extended to cover the overall care afforded to Mrs Hogan, as opposed to focussing on the incident of the fall itself."
He added: "Staffing levels at the time ought to have comprised of seven registered nurses and one clinical support worker (CSW).
"Actual staffing levels were five registered nurses and one CSW.
"The trust regrets this shortage of staff; this staff deficit was due to one shift not being covered, and a member of the nursing team commencing their shift at an earlier time of 4pm as requested by the nurse in charge which led to her finishing her shift at 4am rather than 7am, and prior to the fall."
Mr Scott said the hospital's A&E department had been busy.
'We aim to continue to learn...'
He said: "In the 24-hour period starting at midnight on August 15 and ending at midnight on August 16, the unit was particularly busy with 222 attendances to the department, minimal movement of patients, with many awaiting transfer to beds that were not yet available.
"While we do not seek to detract from concerns raised, we hope this information assists as regards context."
He told the coroner: "In light of the concern noted in your report, the trust has comprehensively considered this matter further.
"Going forward staff have been reminded that if staffing levels are identified as a concern this should be escalated by the senior nursing team and site practitioner to arrange cover.
"Staffing concerns must also be reported on the trust’s incident reporting system - so that these levels may be monitored and kept under review.
"Nursing staff have also been reminded that their twice daily safety huddles in each ward/department should be used to consider all concerns, including any staffing issues.
"We have also introduced twice daily trust-wide safe staffing meetings, chaired by the chief nurse and attended by the divisional directors of nursing and quality.
"These meetings are used to understand risks anywhere in relation to staffing and to identify actions to mitigate these risks."
But Mr Scott admitted Mrs Hogan should not have been left on the trolley and said that it had been against the rules.
He said: "The patient was left in the CDU on a trolley due to the historical department protocol not being followed.
'As a result of this incident, action has been taken to update the department protocol and admission criteria.'
"The patient did not meet the admission criteria for the CDU, however was still admitted to this area.
"As a result of this incident, action has been taken to update the department protocol and admission criteria.
"The updated department protocol and admission criteria has been disseminated to all staff within the department.
"The updated department protocol now states that the unit must be closed if there is no suitable staff allocated to the unit."
Since Mrs Hogan's death, Mr Scott said the Clinical Decision Unit had been re-configured with a new standard operating process which emphasised that the unit was a short-stay clinical assessment area rather than an overnight ward.
He said: "Patients who require admission should not be placed in CDU for any period. If an inpatient bed is required they should be admitted under the appropriate speciality."
Mr Scott said that staffing levels for the unit had also been reassessed.
Senior nursing support has been increased with the successful recruitment of three additional emergency medicine matrons.
He said there was also an active ongoing recruitment campaign for emergency department nurses with regular recruitment days taking place.
Mr Scott said that the second investigation into Mrs Hogan's care had identified issues that were now being addressed with a revised action plan.
As soon as that plan was ready, it would be shared with Mrs Hogan's family.
Mr Scott said: "As evidenced by the re-opening of the internal review of this regrettable event, we aim to continue to learn wherever possible from concerns raised with the trust so as to improve the services we offer to all our patients."
A trust spokesman added: "Policies and procedures to escalate concerns about staffing levels on a daily basis have since been introduced so risks can be identified and any necessary actions taken."
