NHS chiefs have apologised after staff shortages led to the death of a 93-year-old woman who fell from a hospital trolley while waiting overnight to be treated.
Katherine Hogan was left waiting for hours on a trolley in a clinical decision unit (CDU) at Maidstone Hospital in August 2019 but fell off and suffered head injuries that led to her death 15 days later.
Hospital bosses have now admitted they were two nurses short on a night when the A&E department was "particularly busy" – leaving many people waiting for beds.
They also said an internal investigation revealed Hogan shouldn't have been put in the CDU in the first place.
Maidstone and Tunbridge Wells NHS Trust said it has now reviewed its procedures and made changes to prevent similar deaths in the future.
An inquest in July 2020 determined that Hogan "sustained a severe head injury and major haemorrhage due to a high impact fall from a trolley".
Coroner Sonia Hayes noted at the time that Hogan had been left in an area that "was not suitable to keep a patient overnight".
She said: "Staff shortages contributed to the patient being left in the clinical decisions area of the unit on a trolley and those staff shortages had been reported to those responsible for the hospital."
The coroner told the hospital trust: "The inquest revealed matters giving rise to concern.
"In my opinion there is a risk that future deaths could occur unless action is taken."
The coroner issued a Regulation 28 report, requiring the trust to report within 56 days what action had been taken to rectify matters and prevent future deaths.
The trust responded on 11 January, the last day permitted for a response.
Chief executive Miles Scott said: "First and foremost, I have written separately to the family of Hogan to offer my sincere condolences.
"The trust carried out an internal investigation as regards the circumstances leading to the fall sustained by Hogan which was provided to the inquest.
"As part of the trust’s continued objective to learn and improve, this internal review was recently re-opened with the investigation scope further extended to cover the overall care afforded to Hogan, as opposed to focussing on the incident of the fall itself."
He added: "Staffing levels at the time ought to have comprised of seven registered nurses and one clinical support worker (CSW).
"Actual staffing levels were five registered nurses and one CSW.
"The trust regrets this shortage of staff; this staff deficit was due to one shift not being covered, and a member of the nursing team commencing their shift at an earlier time of 4pm as requested by the nurse in charge which led to her finishing her shift at 4am rather than 7am, and prior to the fall."
Scott said the hospital's A&E department had been busy.
He said: "In the 24-hour period starting at midnight on August 15 and ending at midnight on August 16, the unit was particularly busy with 222 attendances to the department, minimal movement of patients, with many awaiting transfer to beds that were not yet available.
He told the coroner: "In light of the concern noted in your report, the trust has comprehensively considered this matter further.
"Going forward staff have been reminded that if staffing levels are identified as a concern this should be escalated by the senior nursing team and site practitioner to arrange cover.
Scott also admitted Hogan should not have been left on the trolley and that it had been against the rules.
He said: "The patient was left in the CDU on a trolley due to the historical department protocol not being followed.
"The patient did not meet the admission criteria for the CDU, however was still admitted to this area.
"As a result of this incident, action has been taken to update the department protocol and admission criteria."
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