First female detective died after catalogue of errors in hospital care
A police forces first female detective died days after suffering three falls in hospital as a result of a catalogue of errors in her in-patient care.
A police forces first female detective died days after suffering three falls in hospital as a result of a catalogue of errors in her in-patient care.
Nearly 50 years ago Sheila Marguerite Graham was welcomed as the first woman officer in Gwent Polices CID.
But the dementia-suffering Miss Grahams last days at the Royal Gwent Hospital in Newport were racked with pain and a final outcome that may have been different, according to an inquest coroner.
The 83-year-old died of a pulmonary embolism on June 30 of this year, Gwent Coroner`s Court heard.
Miss Graham had been admitted to the hospital on May 4 after falling at her home and hurting her hip.
Jenene Edwards, Miss Graham`s niece, told the inquest her aunt became more disorientated in unfamiliar surroundings such as hospitals and told members of staff that she had dementia.
The retired detective constable fell three times while in hospital on May 18, May 19 and June 5. Mrs Edwards said it was absolutely devastating to see her aunt in pain and could see her deteriorating after each fall.
During the third fall Miss Graham, who joined the Welsh force in 1967, fractured her knee.
The inquest heard from Amanda Hale, a senior nurse, for the Aneurin Bevan University Health Board, who gave evidence from the findings of a serious incident investigation report into the care of Miss Graham.
She said on Miss Graham`s admission a risk assessment was carried out but part two of the process was not completed until after her third fall. She said there was no evidence of fall prevention, pain management or dementia plans in place.
Coroner Wendy James, who returned a verdict of misadventure, said: “On the evidence before me, it is clear that there was a catalogue of errors and omissions in the care provided during her stay in hospital which led to three in-patient falls.
“Had she not suffered three falls in hospital the outcome may have been different.”
After the inquest Mrs Edwards said: “As a family we are very pleased the hospital has dealt with our complaint and were very receptive throughout.”
She said they hope the action plan now in place will minimise any risk in relation to elderly people with dementia.
A spokesperson for the Aneurin Bevan University Health Board said: Our thoughts remain with the family of Miss Graham. The Health Board has conducted a thorough serious incident investigation into the care Miss Graham received.
We have met with the family and shared the findings of our investigation fully and openly with them.
The Health Board has already taken corrective actions and steps to address issues raised through our investigation and these actions were positively recognised by the coroner.