A coroner has called for better record keeping of falls by patients by the West Suffolk Hospital, following the death of a retired racehorse trainer from Glemsford.
Richard Casey, 70, had been admitted after suffering a seizure at his home in Bells Lane on February 28 last year and died a month later.
Last week, an inquest at Suffolk Coroners Court in Ipswich heard that while being treated at the hospital in Bury St Edmunds, Mr Casey suffered three falls.
One of the falls, seen by a healthcare assistant, involved Mr Casey sustaining a blow to his head which may have started fatal bleeding on the brain, the inquest heard.
After being helped into bed, Mr Casey was examined and a doctor later ordered a CT scan, which showed no sign of injury.
Three days later, Mr Casey was found sitting on the floor near his bed after suffering an unwitnessed fall and with no obvious sign of injury, other than a laceration to his elbow.
Dr Vivian Yiu said that evening, Mr Casey was found to be unresponsive by a nurse and he was taken for a further CT scan of his head which revealed a large blood clot, although no skull fracture could be seen.
Mr Casey, who medical staff said was at times confused and tried to climb over rails around his bed, died at the hospital on March 29.
Dr Yiu said evidence indicated Mr Casey may have suffered a stroke, possibly unknown to him, in the past but reasons for the seizure at home and others later in hospital could not be identified.
A post mortem examination by pathologist Dr John Chapman concluded that Mr Casey died as a result of an acute subdural haemorhage and bronchial pneumonia.
Giving evidence, Dr Chapman said he found no obvious signs of external damage to Mr Casey’s head.
He said it was possible the fall on March 24 had started bleeding inside Mr Casey’s head, but it could be several days before any signs appear and patients can, in the meantime, appear normal.
The fall on March 27 may have been a result of a build-up of blood near Mr Casey’s brain, said Dr Chapman.
Paul Morris, associate chief nurse at WSH and head of patient safety, said eight members of staff were on duty in the ward when Mr Casey suffered his unwitnessed fall on March 27.
Records did not give any indication of how long Mr Casey may have been on the floor on that occasion, said Mr Morris.
As a result of the fall, a full review had been carried out.
A record of how long Mr Casey may have been on the ward floor before being discovered was inadequate, said Suffolk area coroner Nigel Parsley.
Mr Parsley said: “Had it been more accurate, more timely and full, we would have had a much better understanding of how Richard came by his death.”
“Because of the gaps in the record keeping, and partly because of the nature of the injury that Richard sustained, there are some unanswered questions.
“I do expect there to be an improvement in record keeping in cases which come before me.”
Mr Parsley concluded: “Richard Casey’s death occurred from acute subdural haemorhage which occurred as a result of injuries received in an unwitnessed fall whilst a patient in the West Suffolk Hospital.”