Retired nurse died after fall on Swindon hospital ward

Letitia Kerry, 86, from Penarth in Wales, had visited A&E on February 24, 2023, after her daughter found her in a confused and uncomfortable state at her Covingham home and she was later admitted. 

During her stay at Great Western Hospital’s Jupiter ward, she got out of bed while her nurse’s back was turned and fell, suffering a head injury that led to her death.

An inquest into Letitia's death on Monday morning concluded it was an accident.

But because changes had already been made to the hospital’s policies regarding the monitoring of patients who require an increased level of care assistant coroner for Wiltshire, Ian Singleton, deemed it unnecessary to make a report that would outline further changes to prevent future deaths.

Comments from a relative, read out at the inquest described Letitia as “an incredibly strong woman” who “always lived a full and active lifestyle” and “loved cooking, knitting and family time”.

She worked as a nurse for many years before retiring in the mid-80s after a back injury and then working in private practice during the 1990s.

She remained as active as possible during the pandemic lockdowns but began showing signs of cognitive decline in 2022.

After being admitted to GWH with pneumonia, the medics discovered cancerous growths.

As Letitia required an extra level of care and was deemed to be at high risk of falling, she was placed in a high-visibility bay of four people near the Jupiter ward’s entrance that had one nurse seeing to their needs.

One fall on March 12 caused no further harm or complications and she was deemed fit enough to be discharged, but as medics prepared to transfer her to a suitable nursing home, she fell over again on March 27, which had more serious consequences.

Swindon and Wiltshire Coroner’s Court heard that Letitia’s nurse settled the bay’s four patients in their beds and saw that she was sleeping, so she briefly left the ward to restock a trolley ready for a team that was about to start the day shift.

The nurse then heard a sound and returned to the bay to find Letitia on the floor near her bed after attempting to move to the toilet using a zimmer frame.

Letitia suffered a serious head injury during this fall which led to a slow decline over the following days and caused her to become less responsive.

She remained comfortable until her time of death at 10.35am on April 4. 

Symone Oliver, senior sister for Jupiter ward, apologised and explained that steps had been taken in the following months to reduce the risk of fall-related deaths on the ward.

She added: “Risk assessments were completed and followed. [The nurse] thought the patients were safe and stepped out for a moment.

“We have learned from that fall and put things in place for the future but at that time, we followed the process.

“We as a team are very sorry for what happened and if we could change things, we would.

“As time has gone on, practice has changed, staffing levels have been increased, and specialist enhanced care training for healthcare support workers has been provided.

“Now... the expectation is that a nurse will be in the high-visibility bays at all times, so if someone needs to step out, someone else will cover them.”

In March 2022, 20 falls were recorded in that ward. By comparison, there were eight in February 2024.

The cause of death was primarily a traumatic intracranial haemorrhage sustained in a fall, with carcinomas and old age as secondary factors.

The coroner passed on his condolences to Mrs Kerry’s family.