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Hudgell Solicitors™ | Latest News | Dementia patient died after fall outside hospital where he walked out without staff knowing

Dementia patient died after fall outside hospital where he walked out without staff knowing

Andy and Trevor


NEIL Hudgell Solicitors are advising the family of an 84-year-old dementia patient who died days after being allowed to wander out of hospital alone – falling on the concrete floor and suffering bleeding on his brain.

The family of Trevor Pugh, who suffered from vascular dementia, are being advised on a potential civil case against the University Hospital Southampton NHS Trust after the incident at Southampton General Hospital this summer.

Mr Pugh was admitted to the hospital having suffered a minor fall at home, however, initial examinations showed him to be alert, and that he had suffered no serious damage. He was only kept in hospital for observation, and to await the results of further tests.

Due to his past medical history, in which he was known to wander off when confused, Mr Pugh was transferred from the emergency department to the Acute Medical Unit (AMU), with a consultant identifying him as being at ‘high risk’ of falling again.

However, an investigation into his care has since revealed such concerns were poorly communicated to staff in the AMU when Mr Pugh was transferred from the emergency department, meaning those responsible for him ‘did not care for his dementia needs’.

Panic ensued when Mr Pugh went missing from the AMU on just his second day in hospital, having failed to return after being escorted to the toilet, but then left alone, by a Health Care Assistant.

When the toilet was found empty a search of the entire unit was carried out and Mr Pugh was found on the floor outside the emergency department, bleeding and unconscious, having fallen and hit his head on the concrete.

A CT scan showed he had suffered a bleed on the brain, causing a sub arachnoid haemorrhage. He died less than two weeks later after his condition deteriorated following the development of pneumonia.

On his admittance to hospital, Mr Pugh’s family warned staff of his risk of wandering and his often confused state, and were told he would be treated as being a high-risk patient at all times. However, that turned out not to be the case.

Specialist clinical negligence solicitor Renu Daly, who attended an inquest into Mr Pugh’s death with his family this week, said:” It has been clear from the hospital’s own review of this incident that serious errors were made in the care of Mr Pugh from the moment he was admitted.

“In those first two days at Southampton General Hospital, communication between key members of staff were very poor, so much so that the people caring for him didn’t associate his confusion with his diagnosis of vascular dementia.

“This confusion led to a poor, neglectful standard of care, which ended with Mr Pugh leaving the ward alone and suffering the fall that ultimately led to his death.”

Mr Pugh’s son, Andy, 45, said: “My father’s treatment on admission to Southampton Hospital was simply abysmal from the point of him being admitted to him suffering the fall that ultimately led to his death.

“We warned the hospital that he was prone to wandering off. It happened so often that I had a GPS tracker on his keys so that I could keep an eye on him when he was at home. It was a clear warning from us, but on the first day we visited, when we arrived on the AMU ward the staff didn’t know where he was, and he was found in a toilet alone.

“When he went into hospital following his fall at home, we actually felt he was in the safest place because people would be watching him, but he wasn’t cared for at all and he was completely neglected.

“It’s hard to understand how a hospital can make such mistakes. It has admitted that information on his dementia wasn’t passed from the emergency ward to the AMU, but surely that is the most basic of procedures to follow?

“He wasn’t the first elderly person, or patient with dementia to be admitted to hospital. You expect hospitals to be able to handle things like this.

“We also can’t understand how he was able to walk so far without being stopped. He will have passed a couple of nursing stations, and walked down corridors and through a couple of double doors. It is shocking.”

Mr Pugh says his father had lived alone, with care workers visiting him regularly due to his dementia. The family had long been seeking to secure a flat within a residential care complex for Mr Pugh to move into, and actually had a bid accepted whilst he was in hospital.

“Had that flat become available a week or so earlier I am sure he’d still be with us today,” added Mr Pugh’s son.

“Despite suffering the fall at home, he was in decent health and alert. They were initially talking of releasing him the next day, but kept him in another night as they were awaiting some further test results.”

A Root Cause Analysis Investigation Report highlighted a lack of consistency in allocating nursing staff to Mr Pugh, saying that also resulted in a lack of continuity in his care, with staff on the AMU not linking his confusion to dementia.

The report recommended a number of changes to improve communication at the hospital, and that exits on the AMU unit be upgraded with the introduction of a push button system to alert staff when patients attempt to leave the ward unattended.

But for Mr Pugh’s family, who are still to receive an official apology, it brings little comfort, as did an inquest this week in which the coroner recorded a narrative verdict.

“It was good to hear at the inquest that changes have been made to prevent something like this happening again, but it did seem a case of just going through the motions and allowing the Trust to highlight what measures have been implemented since,” said Mr Pugh’s son.

“It was poor for the entire time he was in the AMU. Communication was so poor that one day, when my father’s health had deteriorated further, staff tried to feed him, even though he was nil by mouth.

“To this day we have still not had a full apology, and nobody appears to have taken any real responsibility for what happened to my father.  That makes us feel very let down, and very sad.”

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Renu Daly

Solicitor, Clinical Negligence

rd@hudgellsolicitors.co.uk

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