Coroner raises concerns over hospital probe into elderly woman's death
The inquest heard evidence that the patient who pushed Mrs Pomeroy should have been the subject of "enhanced observations of care" and that the incident was foreseeable
A coroner has raised concerns about an internal hospital investigation into the death of an elderly woman who died after she was pushed over by another patient who had carried out similar attacks previously.
Mary Pomeroy, 89, suffered fatal injuries after being pushed to the ground on a ward at Derriford Hospital in Plymouth in March 2022.
The inquest in Exeter heard she died as a direct result of the push from the patient who had "psychiatric, behavioural and cognitive difficulties" and who had done the same thing to another person on the ward two days before.
The same patient had also been involved in other incidents where they had used physical force on staff members on the ward the month before.
An internal investigation concluded that Mrs Pomeroy's death was "a rare and devastating accident which could not have been foreseen".
The inquest heard evidence that the patient who pushed Mrs Pomeroy should have been the subject of "enhanced observations of care" and that the incident was foreseeable.
Assistant coroner Nicholas Lane said the patient was "not being closely supervised in the ward" and issued a prevention of future deaths report to the hospital's trust and chief nursing officer.
In his report, he said: "It is unfortunately clear, when comparing the evidence heard at the inquest with the findings of the root cause analysis report, that there was inadequate analysis of this serious incident by the hospital trust, with concerning circumstances surrounding the care provided not being identified.
"Therefore, appropriate recommendations to inform future care provision were not given consideration as part of the root cause analysis investigation/report.
"If the hospital trust does not identify concerning matters when carrying out internal investigations and do not take steps to try and learn from serious incidents when they occur, then there is an obvious, significant and continuing risk of future deaths occurring arising out of healthcare provision provided."