Woman died after two falls at hospital

A sensor mat was not enough to stop a 77-year-old Geraldine woman from a fall, which potentially contributed to her death, a coroner heard yesterday.

Valerie Joan Hepburn was taken to Timaru Hospital on August 23, 2012, after she fell twice at her home. She suffered two further falls in hospital the following day, the second resulting in a knock to her head and lacerations to her limbs.

She had a CT scan and transferred to Christchurch Hospital the next day for surgery after suffering a haematoma to her head. She died on September 6, 2012.

Mrs Hepburn had been sitting in a lazy-boy chair at the time of her second hospital fall. Nursing staff assume she had attempted to get out of the chair, but avoided putting her feet on a sensor mat in front of her chair.

The mats are designed to alert staff when a patient becomes mobile. However, some patients see it as an obstacle, while others believe it is a large hole in the floor because of the mat's colouring, South Canterbury District Health Board (SCDHB) solicitor Craig O'Connor said.

Efforts had been made by nursing staff to make Mrs Hepburn more visible to staff by moving her chair and the sensor mat.

Registered nurse Megan Clinch said a falls risk assessment and action plan had been made, based on her earlier fall. However, staff could not monitor her more regularly than other patients because of a shortage of staff.

"We were seven or eight staff down at the time," she said, of the 20 who would normally be rostered on.

Mrs Hepburn's husband, Don, questioned why he had not been informed of the staff shortage.

"If I knew [the hospital] didn't have the staff available I would have organised security staff to sit with her."

Penny Shrimpton, Mrs Hepburn's daughter, said there appeared to be a break-down in communication. She also questioned why a safety harness could not be used.

Board director of nursing and allied health Jane Brosnahan said safety harnesses were not routinely used because they had been known to strangle people.

She said a range of other measures were now in place, including safety pads which patients sit or lie on. The pads alert staff once patients are starting to move, not when they are already mobile. Grip socks are also being used to prevent patients from slipping over.

Mr Hepburn took a moment during the inquest to thank the staff for looking after his wife.

"I do appreciate what they've done over the years," he said.

Coroner Richard McElrea reserved his decision. However, he ruled that Mrs Hepburn died of aspiration pneumonia.

The Timaru Herald