A serious incident review has been carried out at Kettering General Hospital and changes made after the death of a great-great-grandmother.
Ivy Brayfield, 88, died last November after being in hospital for ten days.
Hospital bosses have admitted failures after the former army cook died after suffering two falls in three days.
An inquest heard doctors should have put in place a ‘five step action plan’ when the pensioner was identified as at risk of a fall but it wasn’t.
Staff also failed to carry out a full mental capacity test after Mrs Brayfield scored only four out of ten in a list of simple questions.
A serious incident review was carried out at Kettering General Hospital and bosses told the inquest changes have been made.
Recording a verdict of accidental death, assistant Coroner for Northampton Hassan Shah said: “It is clear that lessons have been learnt and I hope the recommendation in this report are implemented.”
Penny Brett, director of nursing and quality at the hospital who carried out the review, said: “There was no implementation of action. A care force bundle, which is a five step action plan should have been actioned when a fall risk has been identified.
“These preventative measure were not taken. They include providing a low-rise bed, which may or may not have helped, anti-slip slipper, and observatory beds. In some respects some of this was carried out because Mrs Brayfield was given anti-slip slippers but this wasn’t documented.”
She said that a number of recommendations have been put in place, including launching a fall prevention campaign.
But Mrs Brayfield’s family feel let down by the hospital and say her death could have been “prevented”.
Her daughter retired cleaner Liz Swannell, 59, said: “We feel that she could have had one last Christmas with us playing with her grandchildren.
“She died because of a fall and they have admitted that could have been prevented. We feel they robbed us of one final Christmas with her.
“But we’re happy that changes seem to have been made and as the coroner said I just hope these are implemented to stop this happening to someone else.
“We are very disappointed with the hospital and the care our mother received.”
Mrs Brayfield, who was suffering with the early stages of dementia, was admitted to hospital last November 10.
The widow, who also had thyroid problems and chronic obstructive pulmonary disease (COPD), had been regularly vomiting and suffering with severe headaches. She underwent a CT scan and was found to be suffering from advanced cancer of the left lung and kidney.
The coroner’s court in Kettering heard Mrs Brayfield, from Little Harrowden, was confused and restless when she was admitted to hospital.
On November 16 she fell from the the chair next to her bed and suffered a cut to her eyebrow.
Three days later she fell again but this time it resulted in a massive head injury that was made worse because she was taking Warfarin, a drug which thins the blood.
Her family has criticised the hospital after staff took more than four hours to contact them. And it took until midnight for Mrs Brayfield to be seen by a doctor after the fall at 9.40pm.
A CT scan showed the fall had left Mrs Brayfield with a left subdural hematoma and hemorrhage.
A pathologist told the inquest the delay in having a CT scan and a drug being administered to reverse the effects of the Warfarin would not have changed the outcome.
Senior house officer Dr Bebitha Markose told the inquest Mrs Brayfield was not prioritised as another patient would have “died straight away” if they had not been seen first.
But the hospital apologised to Mrs Brayfield’s family and admitted staff should have escalated the call further to access another doctor.
Mrs Brayfield had five grandchildren, eight great grandchildren and one great great grandchild.
A spokesman for Kettering General Hospital said: “The Trust has sincerely apologised to Mrs Brayfield’s family. It carried out a thorough review into the circumstances of her care and has taken a series of actions to address the issues raised.”
Verdict: Accidental death