Catterick woman died after fall going to toilet at Darlington hospital

Shannon Scorer, from Catterick Garrison, attempted to get up unaided when she fell on October 23 last year - the day she was admitted.

She had been unwell for the previous few days with complications relating to her alcoholism.

An inquest looking into the circumstances surrounding her death heard Ms Scorer suffered a traumatic brain injury and was transferred to James Cook Hospital in Middlesbrough for treatment.

Tragically, she died on October 26.

A hospital spokesperson said they were committed to learning from Shannon's death.

Ms Scorer was identified as being at a low risk of falling by staff, Senior Assistant Coroner for County Durham and Darlington Crispin Oliver heard.

The inquest was told she had not been told to call for help when she needed to use the bathrooms.

"Had she been told to use the call bell to summon assistance to go to the toilet, on a balance of probabilities, she would have done so," Mr Oliver said.

"It was possible it would have been responded to and therefore possible that she would have been escorted to the toilet and possible that the fall would not have happened," he said.

The ward at Darlington Memorial Hospital was understaffed due to illness on the night Ms Scorer fell and her fall was only witnessed by a fellow patient, the inquest heard.

Shannon was assessed by staff and considered to be fully alert and oriented after the fall, but was taken for a CT scan which found a mild traumatic brain injury. 

Staff were told to check on her hourly overnight but two of those checks were missed, the court heard. The missed checks were not found to have contributed to her death.

A consultant told the Coroner he would have called haematology to discuss the CT scan results if he'd been asked, but the court heard they were not asked for any further input. 

Dr Irfan Khan, a consultant physician at Darlington hospital who was on call at the time, told the inquest: "If I would have been rang after the CT scan and told there was a bleed on the brain, I would have said to discuss with haematology."

"The evidence in this inquest was that haematology input should have been sought," Mr Oliver said. "This itself was a significant omission."

Instead, a call was made to James Cook Hospital in Middlesbrough, who advised that surgery was not necessary at that point.

The court heard a transfusion could have happened around 40 minutes later, but it was unlikely that this would have entirely corrected the bleed on the brain.

Shannon was seen by staff three times the morning after her fall before she was found unresponsive at 7.58am.

Another CT scan showed the bleed on her brain had worsened. She was sent in an ambulance to James Cook Hospital but sadly died there on October 26.

Her cause of death was given by Dr Richard Graham as a brain injury relating to a fall, with alcoholic liver disease indirectly contributing.

The inquest concluded Ms Scorer died "from the consequences of a fall."

Addressing Ms Scorer's family, Mr Oliver said: "I am acutely aware that Shannon was only 30 and this was not a good way to go, and I am really sorry about it."

A spokesperson for County Durham and Darlington NHS Foundation Trust said: "We offer our sincere condolences to the family of Shannon Scorer on their loss.

"We recognise the concerns that have been raised and take matters of this nature extremely seriously.

"As is standard practice following any patient fall, a rapid review was undertaken.

"Patient safety remains our highest priority, and we are committed to identifying and acting on any learning where improvements can be made."