An elderly woman died after suffering a number of falls at a Burnley care home.
Mrs Margaret Johnstone (86) died on July 8th, 2014, at the Sun Hill Care Home in Manchester Road, Burnley, two months after she had undergone surgery on a head injury.
A two day inquest at Burnley Town Hall heard evidence from a number of medical staff who treated Mrs Johnstone in Burnley General Hospital, the Royal Blackburn Hospital and Preston Royal Infirmary, where she underwent the surgery.
East Lancashire Coroner Mr Richard Taylor, who recorded a narrative conclusion, said that the quality of recording incidents at the care home and the fact Mrs Johnstone could not be watched at all times meant it was unclear which fall had caused her serious brain injury.
Pathologist Dr Walid Salman, who conducted a post-mortem examination, gave the cause of death as bronchopneumonia caused by a subdural haematoma, caused by falls.
Mr Taylor said: “Mrs Johnstone had suffered various falls over at least the seven years before her death, and had attended the falls clinic on a number of occasions over those years.
“In 2013 she suffered a fall which broke her femur. She also had a medical history which included cancer, diabetes and cognitive impairment.
“She suffered a fall on February 25th, 2014, as a result of which she attended hospital. It is of note that this was the only time she went to hospital in 2014 as a direct result of a fall.
“I have no doubt that due partly to the quality of recording incidents at the care home, and the fact that Mrs Johnstone could not be watched at all times, that there must have been other incidents of trauma, which however slight, the consequences could not have been anticipated.
“The evidence of what actually caused the injury which led to her death, and when that was, is unclear.”
Neurosurgeon Mr Nihal Gurusinghe, who operated on Mrs Johnstone in Preston, told the inquest that his team had interpreted a CT scan on February 27th as showing that there was already a subdural haematoma before the fall of February 25th.
Mr Taylor added: “While the operation on May 1st was successful by releasing the pressure on Mrs Johnstone’s brain, she never recovered from the debilitating effects and due to frailty there was nothing the hospital could offer and she returned to Sun Hill where she sadly died on July 8th.