A seriously dehydrated pensioner died after being found on the floor next to his hospital bed, an inquest has heard.
Anthony Blower, 83, from Petersfield, Hampshire, fell at the Queen Alexandra Hospital in Portsmouth in October 2020.
His condition deteriorated and he died at home 11 days later.
Assistant Hampshire coroner Robert Simpson said a falls risk assessment was not fully completed when Mr Blower was admitted and his dehydration was not sufficiently addressed.
The pensioner suffered a number of falls at home in September 2020 and was diagnosed with bilateral subdural haematoma [bleeding on the brain], the coroner said.
After his hospital fall on 14 October, a CT scan revealed further bleeding and he was given palliative care.
Mr Simpson said Mr Blower’s age and multiple pre-existing medical conditions affected his treatment and recovery.
However, he said there was a risk of future deaths because of issues at the hospital.
In a report to the Chief Coroner, he said: “The multi-factorial falls risk assessment had not been fully completed on admission nor fully updated after an in-patient fall by Mr Blower.
“I note that the hospital is carrying out audits of documentation completion and updating some systems.
“However, some two years after the death of Mr Blower, the ward manager stated… that concordance with documentation remained poor.”
The coroner added that Mr Blower was given intravenous fluids during his admission and his drinking was monitored, but “this was not sufficient to prevent Mr Blower from becoming seriously dehydrated pensioner.
Portsmouth University Hospitals NHS Trust has been approached for comment.
Article provided by BBC News