A coroner has called for a hospital to keep better records of falls by patients following the death of a former Newmarket trainer.
Seventy-year-old Richard Casey was admitted to West Suffolk Hospital after suffering a seizure at his home in Glemsford on February 28 last year and died a month later on March 29. On Wednesday, an inquest in Ipswich heard that while being treated at the hospital Mr Casey suffered three falls.
One of the falls, witnessed by a healthcare assistant, saw Mr Casey sustain a blow to his head which may have marked the start of fatal bleeding on the brain, the inquest heard. He was examined by a doctor but a CT scan showed no sign of injury.
Three days later, Mr Casey was found sitting on the floor near his bed after suffering an unwitnessed fall. Consultant Dr Vivian Yiu said 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.
Dr Yiu said evidence had been found that, possibly unknown to him, Mr Casey may have suffered a stroke in the past but the reasons for the seizure at home and others later in hospital could not be identified.
A post-mortem examination concluded that Mr Casey died as a result of an acute subdural haemorrhage and bronchial pneumonia.
Pathologist Dr John Chapman said he had found no obvious signs of external injury to Mr Casey’s head but it was possible the fall on March 24 had started internal bleeding.
Paul Morris, associate chief nurse at the hospital and head of patient safety, said eight members of staff had been on duty in the ward when Mr Casey suffered his unwitnessed fall on March 27 but records did not give any indication of how long he may have been on the floor. As a result a full review had been carried out.
Suffolk area coroner Nigel Parsley criticised the lack of a record of how long Mr Casey may have been on the ward floor before being discovered as ‘inadequate’.
“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,” he said. “I do expect there to be an improvement in record keeping in cases which come before me.”
He concluded Mr Casey died as a result of injuries received in an unwitnessed fall in hospital.
Mr Casey rode as an apprentice for Cecil Boyd-Rochfort and, as a pre-trainer in Dullingham, worked with horses which became stars for Sir Michael Stoute.