Patient died falling off trolley

By Michele Paduano
Health Correspondent, BBC Midlands Today

The patient who died suffered bleeding to the brain and a cardiac arrest

Directors at Stafford Hospital considered shutting down a unit last month after a patient fell off a trolley and died, it has been revealed.

It was the second fall in three months from a trolley at the hospital.

The Health and Safety Executive and the Care Quality Commission have now been called in to investigate at the Clinical Decision Unit (CDU), part of accident and emergency where patients are monitored before they are discharged.

The patient, whose age and sex are not known, suffered bleeding to the brain and a cardiac arrest after the fall.

The patient then died during surgery.

A draft report by the hospital which has been seen by the BBC said the casualty had been drunk but no risk assessment was carried out on them.

An A&E doctor was called, but no CT scan was ordered. There was no referral to a surgeon and the report suggested moving the patient to the CDU then was inappropriate.

The incident went unreported and only came to light because the patient died.

'Inappropriate comments'

The investigations are also looking at whether the casualty was only moved into the CDU at that point to avoid staff breaching the maximum waiting time of four hours in accident and emergency.

The hospital's report also revealed a nurse had been overheard making inappropriate comments about the patient.

It said action would be taken against that nurse and against those who failed to carry out a risk assessment.

Mid-Staffordshire NHS Trust said it was now considering buying low trolleys to use for patients at risk of falling.

The report said action would be taken against several members of staff

In a statement, the hospital added that the smaller area of the CDU, which is made up of two separate areas, had been shut following concerns about "being able to safely monitor staff and patients" there.

It also said staffing levels had been increased in the larger area of the CDU to ensure good care could be provided.

However, it is not clear exactly when the hospital took this action.

The statement added: "These incidents are being investigated and the actions described above demonstrate our commitment to eradicate any concerns around patient safety without delay."

In March, the Mid-Staffordshire Foundation Trust was lambasted by the Healthcare Commission for its "appalling" care which could have led to 1,000 unexplained deaths.

Nurses at the time said the CDUs were used to avoid breaching the four-hour waiting targets and staff were not clear about their purpose.

Lobby group Cure the NHS has called for the hospital to be shut completely for six months so that treatment levels can be brought up to standard.