Man who fell died of traumatic brain injury

The death of a 56-year-old Congleton man was caused by traumatic brain injury, a coroner concluded on Monday, although it was “not possible” to pinpoint the exact trauma that caused it.
Matthew John Waby, of Moston Court, died at Royal Stoke University Hospital on Christmas Day, 2018, a resumed inquest at Macclesfield Town Hall was told.
 He “was prone to falls due to high alcohol intake” and suffered at least two in the days leading up to his death — one of which was at Macclesfield District General Hospital.
The Chronicle reported last June that the inquest into Mr Waby’s death had to be adjourned when it emerged that members of his family were not initially aware of the fall he had while in hospital and that the court did “not have the information” it needed to continue.
The court had heard that Mr Waby was taken to Macclesfield District General Hospital on Monday, 17th December 2018, soon after he fell in Congleton town centre.
Paramedics described treating Mr Waby for a 3cm wound that was actively bleeding, while nursing staff at the hospital said Mr Waby had told them he had consumed half a bottle of vodka.
When the inquest resumed this week, Janet Napier, assistant coroner for Cheshire, was told by Elizabeth Owen, a registered general nurse at Macclesfield Hospital, that Mr Waby was admitted to the hospital on a day when it was “under huge operational pressure”.
She said there had been “significant crowding”, Mr Waby had to be nursed in the corridor and the A&E department was temporarily understaffed. Exacerbating the situation further, eight ambulances were received between 4pm and 5pm.
At about 5.30pm, Mr Waby had to be helped off the floor in the patient toilets, as he had fallen again. He was treated for a bleeding head wound, which was dressed. Staff were informed that he would need a full risk assessment and an incident report. 
Mr Waby was given a CT scan following both his falls. However, his fall in hospital was not recorded in all of his admission notes. The court heard that a nurse had submitted an incident form that said Mr Waby had fallen, but that fall was not referenced at all in some of the doctors’ records.
Ms Owen told the coroner that “many lessons” had been learned from the issues with hospital records and that a number of changes in the way incidents were recorded had been looked into.
These included introducing “tick boxes” that should be updated hourly by nurses, carrying out audits on the cards passed on to doctors by nurses with their assessments, and improving “multi-disciplinary huddles” — short briefings in which team leaders came together to share clinical information and plan for the day ahead.
She said: “There are huge pressures within our trust as well as nationally. We have been under extreme pressure for a number of months now.”
The inquest heard that after Mr Waby was discharged from the hospital, he consumed more alcohol. His wife, Susan, said she later found him “passed out” on the bedroom floor and she had tried to shake him awake for some time, but he was not responding. She phoned the emergency services and an ambulance took him back to hospital in Macclesfield.
A statement from the paramedic said Mr Waby’s “jaw was locked, indicating significant head injury”.
He was transferred to Royal Stoke University Hospital. On the morning of 18th December, nursing staff were unable to wake him. He was given palliative care, and it was felt it was in Mr Waby’s best interests that he was not to be resuscitated.
He died at the hospital on 25th December 2018.
Ms Napier concluded: “It is not possible to accurately pinpoint the actual trauma that caused the bleed. It is known that bleeds can start some time after a fall.
“Investigation made into Mr Waby’s death highlighted the extreme pressure hospitals are facing; this appears to be a national problem.
“Changes have been made, although they depend on patient flow and staffing.
“There was no possibility of any extra help being given in A&E. Mr Waby died on 25th December 2018 at Royal Stoke University Hospital. The cause of death was traumatic brain injury.”