PROBLEMS have been found after a patient died after falling from her bed at a Herefordshire hospital.

Herefordshire coroner Mark Bricknell issued a prevention of future deaths report after an inquest held in July concluded that Rita Howells had died an accidental death.

Mrs Howells was admitted to Bromyard Community Hospital in March last year, but was transferred to Hereford County Hospital, where she later died from an intracerebral haemorrhage, after suffering a fall on the ward.

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The coroner's report said the evidence given during the inquest had raised concerns that bed rails are routinely erected before falls assessments, contrary to policy as advised, and that the procedures to establish whether a call bell is working are unsatisfactory.

In a recently published response to the coroner's warning, a Wye Valley NHS Trust spokesperson said Mrs Howells had an unwitnessed fall from her bed while attempting to get to the toilet on March 15.

She told staff she was unable to call for help to walk as the call bell was broken.

Mrs Howells was taken to Hereford's emergency department and was transferred back to Bromyard the following day, the spokesperson said. 

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A CT scan carried out on March 23 after concerns were raised about behavioural changes showed acute cerebral haemorrhagic contusions and Mrs Howells died on April 28 after receiving palliative care.

An investigation found incomplete falls risk assessments, a bedrail assessment was not updated on transfer to Bromyard, the bedrails were raised at the time of the fall despite an advisory on the last assessment that they should not be used, and that Mrs Howells was receiving less supervision than the last assessment had advised.

The call bell was also known to be broken by non-clinical staff, but this was not reported to clinical staff, and there was no process to routinely check call bells are working.

The spokesperson said audits had found recurrent issues involving bed rails.

"The recurrence of the issue suggests a ‘habitual’ positioning of bed rails," the spokesperson said.

The spokesperson said measures have been taken to improve communication of falls risks and bed rail positions at handovers and in patient bays, while they are also seeking to standardise the frequency of call bell checks across the trust's locations.

Yellow falls risk socks and wristbands trialled in the frailty unit are also being rolled out across the trust, and a trial of securing bed rails down with a yellow cable tie until a bed rail assessment is completed is being carried out.