An elderly dad-of-three died after he fell from a trolley in an A&E waiting room.
Richard Smith was rushed to hospital on Boxing Day 2020 after he was found on the floor of his bedroom at the Key Healthcare care home where he lived.
The 90-year-old had only suffered minor cuts but was taken to A&E at Whiston Hospital, Prescot, Merseyside, for a check-up and CT scan, and was placed on a trolley, in a cubicle.
But barely half an hour later, at 6.50pm, the dad who suffered from dementia was found on the floor outside the cubicle, having fallen from the trolley and broken his left hip.
At an inquest today, the court heard that the retired mechanic had been looked after by his family in St Helens, Liverpool, until the beginning of December 2020 when he was admitted to the same hospital.
On Christmas Eve, he was transferred to a care home, just to end up back at the hospital two days later.
After his fall, he underwent surgery for a broken hip on December 27, but on January 3, Richard suffered a gastrointestinal bleed.
His condition continued to decline and he was placed on palliative care, before he sadly died on January 19.
Whiston Hospital emergency department matron Susan Hobbs said Richard had been classed as being at high risk of falling, and that he needed "one-to-one care, or if not that, one-hourly checks".
However this did not happen, and nurses were unable to say when the 90-year-old fell from his trolley.
There had also been "a significant delay" in the hospital's investigation into the incident, as it had not been properly reported.
She said: "We knew an incident report was completed, that Mr Smith had fallen and sustained a fracture, but that was never escalated up the line and the senior manager was not aware. It wasn't until later on that we learned Mr Smith had suffered a fracture."
She added: "I spoke to the nurse that had looked after Mr Smith and she couldn't give a reason why she didn't escalate it and it was a lesson learned for her. We did some reflection and she understands the catastrophic impact it had, because investigations weren't started promptly."
A number of changes have been put in place at both Key Healthcare and Whiston Hospital to prevent further incidents since Richard's death in 2021.
Key Healthcare operations manager Lin Spencer said risk assessments in all the provider's homes, like Richard’s, are now "more robust", and that sensor mats had been put down to alert staff should residents fall out of bed.
Ms Hobbs said documents at the hospital had been updated and shared with staff, and that low trolleys had been placed in A&E to prevent further fall injuries.
Coroner Julie Goulding handed down a conclusion of accidental death.
