A RETIRED linesman and artist died in hospital in Barrow after a 'clear lapse in care' led to a fall which left him with a broken hip and pelvis, an inquest heard.

Norman Foster, 84, died on September 3, 2022, after a five-month stay in Furness General Hospital led to his ultimate death from pneumonia.

Mr Foster was admitted to the hospital on April 1 after a fall and episodes of confusion.

He suffered from a number of physical and mental ailments including heart failure, mobility issues, confusion, and manic disorder with psychosis.

Assistant Coroner for Cumbria Craig Smith, heard from Diane Charlton, Ward Manager at Furness General Hospital, that Mr Foster had suffered a number of falls, largely unwitnessed, during his hospital stay.

She said that he would 'overestimate his own capabilities' and try to walk around the ward, refusing to wear the non-slip socks issued by the hospital.

He habitually used a walking stick but was given the use of a wheeled zimmer frame with a view to potential discharge but would 'mobilise very quickly, going too fast' with the frame, she said.

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Mr Foster was deemed to be a 'severe falls risk', and Mr Smith heard of one 'key incident' on July 28 when a member of staff who was helping him wash and change left him briefly behind a closed door in a room while she went to fetch some linen.

Mr Foster fell, with an x-ray showing he sustained a broken rib and a fractured pelvis.

His health subsequently deteriorated and he suffered a traumatic haemothorax (blood in the lung caused by a trauma such as broken rib).

He developed pneumonia and following a severe deterioration on August 11, and discussions with his family, was placed in end-of-life care from August 15.

Ms Charlton was asked by Mr Smith about staffing and procedural pressures at the hospital at this time.

She said that there was 'a lot of strain on staffing', due to large numbers of staff sicknesses and the volume of patients admitted, leading to more 'escalation' beds being needed.

She said that improvements have been made since then, with administrative improvements being made, leading to more regular checks, a dedicated 'falls champion', and a reduction in the time any member of staff would monitor fall-risk patients.

This is to 'reduce the risk of fatigue'.

Ms Charlton said that after a staffing review, the hospital had recruited an extra eight members of staff – which she said was 'huge'.

Concluding, Mr Smith said: "I am satisfied that on the evidence, Norman's death was closely connected to the injuries sustained in the fall on July 28.

"I am satisfied that there were identifiable lapses in the care that may have contributed to the falls being  occasioned in this case"

Mr Smith also decided that while Mr Foster’s fall on July 28 'most likely' was a contributory factor in his death, staff actions fell short of neglect.

He noted 'similarities' to an inquest in 2020, where similar issues were raised at the hospital.

He said: "In a perfect world there would be no falls for any patients in hospital but it would take a system approaching perfection, which would never be reality.

"Diane (Charlton) gives clear evidence that actions have been implemented, and I do note that actions have been rolled out."

A statement by Mr Foster’s wife, Jean, said he was born in Bentham, Yorkshire, and was a 'Yorkshireman at heart'.

He 'enjoyed walking immensely', and was a keen cyclist, and was a well-known figure around the streets of Ulverston where he lived on Chestnut Grove.

He was also a talented artist and some of his paintings were exhibited at Barrow Arts Society.