A CORONER has raised questions about how falls can be prevented in hospital following the death of a 102-year-old.

Gwendoline Radnor of Buckfield Road, Leominster was taken to Hereford County Hospital on January 14 after experiencing shortness of breath.

The inquest at Herefordshire Coroner's Court heard she was treated for pneumonia and acute kidney injury and was responding well to treatment.

On the morning of January 18 she fell next to her bed in Redbrook Ward and sustained a subdural haematoma, which she died from on February 3.

Coroner Mark Bricknell raised concerns about how bed rails are used.

A care plan had been carried out which said Mrs Radnor should have bed rails up.

However, the inquest heard that if the patient has full capacity and does not want the rails up the nurses will comply with their request.

There were differing accounts from two nurses but the inquest heard this could be because the agency nurse did not complete the forms until five weeks after the fall.

Nurse Nely Apilado said the bed rails were down when the fall happened, while agency nurse, Namukale Simanwe said they were up.

Matron Amanda Palmer said the trust has since amended the documentation and carried out training, so staff can now make it clear whether bed rails are needed and whether they have been declined. There is also now more space to write further detail.

Ms Apilado, who had attended to Mrs Radnor during the night before her fall, said Mrs Radnor had not pressed the call button and she had gone to assist her to go to the toilet when she had seen her getting out of bed.

Mr Bricknell said there should be signs alerting patients to the call button to encourage them to use it.

Ms Apilado was attending to another patient's call button when she saw Mrs Radnor fall as she was trying to get out of bed.

When Mr Bricknell said alternatives need to be considered to prevent falls such as bed sensors or lower beds, Ms Palmer said the hospital had tried bed sensors but they were unreliable. She said this was being looked at again.

Mrs Radnor's daughter, Eileen Hackley, raised concerns that her mother's zimmer frame was placed out of reach and that the call button would sometimes fall on the floor. She also said she had asked for the bed rails to be up.

Mr Bricknell recorded an accidental death. He said she died from a subdural haematoma but noted the fall and her frailty.

He asked to arrange a meeting with hospital staff to talk about bed rails.