An inquest into the death of a Blackheath pensioner has revealed a catalogue of errors at Queen Elizabeth Hospital and prompted a letter by the coroner to warn about national staffing levels.
Violet Wood, 94, was admitted to Queen Elizabeth Hospital, Woolwich, on January 26 2012 after having a fall at her Hervey Road home. But during the retired civil servant's stay on an understaffed ward she fell three more times, suffering a head injury that eventually killed her.
A Southwark Coroners Court inquest heard that, following the falls, results of a CT scan were not shared between medical staff, vital checks on her mental condition were not carried out and documentation of her care was left incomplete or crossed out - something the coroner warned "can indicate some intention to mislead".
Coroner Sarah Ormond concluded there were "quite a number of failures" and, though these did not actually cause the death, they troubled her sufficiently enough to consider taking "severe" action.
During the two-day inquest, doctors and nurses from Queen Elizabeth repeatedly said that Mrs Wood needed one-to-one supervision to stop her falling but there just were not enough staff available.
Head of nursing Jemma Wells, who said more staff were being recruited, was asked if the ability to access bank or agency nurses and carers was better or worse today. She replied: "I think accessing quality staff is worse."
Mrs Wood fell three times, slightly hitting her head on January 28 and banging it more seriously in the early hours of January 29. She was scanned for a head injury but staff on the ward were unaware of the results until they were informed around six hours later by a family member.
A usual morning meeting was not held because it was a weekend while Mrs Wood did not undergo neurological observations and was allowed to sleep - despite the fact this could indicate her condition was worsening.
However, Doctor Alex Taylor told the inquest that, even if extra checks had been carried out, it would have made little difference as Mrs Wood had suffered a subdural haemorrhage, eventually leading to her dying on January 30 from bilateral pneumonia.
He said: "The older you are, with this particular kind of brain haemorrhage, the less likely you are to survive even with treatment."
The coroner concluded Mrs Wood had died as a result of an accident or accidents.
And she added she would be writing to the hospital determine whether she should contact the Department of Health "in relation to the lack of carers or nurses to look after patients that are at high risk of falling."
She went on: "This is not an issue that I'm taking to be one which is particular to Queen Elizabeth Hospital."
Speaking afterwards, Mrs Wood's great nephew Peter Dowdell, 58, said he would be writing to the Health and Safety Executive urging them to investigate.
He said: "The facts remain that Violet died as a result of injuries sustained whilst in hospital care. But accidents happen and we know that.
"We're comforted that, as a direct result of Violet's death, the serious incident report by the trust and the inquest, changes have been and continue to be made so this should not be allowed to happen again, especially if, as the coroner implied, there are national implications.
"However, the serious incident report took 17 months to prepare and hence the delay in holding this inquest. We believe this has added to our distress as a family and is wholly unreasonable.
"Whilst mistakes were made at the sharp end in care delivery the responsibility for the care and its quality lies directly with the senior managers and board members who make policy decisions and hold the purse strings."
Nursing levels reviewed
A spokesman for for Lewisham and Greenwich NHS Trust, which took over the hospital last year, said: "Our thoughts are with the family of Mrs Wood and we send our condolences.
"This event took place in January 2012 and Lewisham and Greenwich NHS Trust cannot comment on the policies and processes of a previous organisation i.e. South London Healthcare NHS Trust, but we take any such death seriously and work continuously to improve our patients' safety.
"Since Lewisham and Greenwich NHS Trust was formed (in October 2013) we have carried out a thorough review of nursing staff levels.
"This review has enabled us to set staffing levels appropriately for the wards, and measures are in place to ensure swift action is taken to resolve any staff shortages."