THE inquest of a Prudhoe pensioner who died earlier this year was held in Northumberland.

James Robert Blackburn, known as Bob, died in March at his home on West Wylam Drive.

The inquest, on October 26 held at Northumberland Coroner's Court at County Hall in Morpeth, heard Bob had a complex medical history and suffered from conditions including ischaemic heart disease, hypertension, Type 2 diabetes, and stage 4 chronic kidney disease.

On January 1 this year, the 83-year-old was admitted to the RVI in Newcastle before he was transferred to an adult renal ward at the Freeman Hospital the following morning.

A falls risk assessment was undertaken and it was decided Bob was to have one-to-one enhanced care by a nurse or healthcare assistant.

Julia Ibbotson, Matron for Urology and Renal Services at Newcastle Hospitals NHS Foundation Trust, told the inquest that staffing at that time was "probably the worst it's ever been" due to high levels of Covid-19.

While Bob received one-to-one care by a nurse throughout the day, he did not after around 9.15pm following the change of shift.

Ms Ibbotson said the ward began the shift with reduced staff, and that three patients, including Bob, required one-to-one enhanced care.

Three extra healthcare assistants were requested but only one was available.

As Bob had seemed "quite settled" and appeared to be asleep at the time, staff made the clinical judgement that another patient required the one-to-one care more, Ms Ibbotson told the inquest.

She added they had contracted the site manager to say they needed extra staff, and said the situation was escalated appropriately.

At 10pm on January 2, a nurse entered Bob's cubicle and found him on the floor having suffered a fractured neck of femur and he underwent a dynamic hip screw procedure.

"There's real regret that we were in the situation that we could not provide that one-to-one care at that time," said Ms Ibbotson.

She also told the inquest the use of bed rails for Bob would usually have been a contraindication as due to the confusion he was experiencing, he could have tried to climb over them, increasing the potential height of a fall.

While he received one-to-one care, bed rails were in place, but Ms Ibbotson said this was overridden by having a nurse with him all the time. 

"Often patients feel more secure with bed rails," she said. "I think it's reasonable that they were there throughout the time."

The bed rails were also in place for the period when Bob was not monitored, and Ms Ibbotson said in hindsight they have questioned whether they should have been put down but said staff had "not really thought it through because they found he was settled".

Bob remained in hospital following his surgery and had dialysis for a short period. 

Bob's renal function gradually declined after he was discharged from hospital on February 1, and he later received palliative care. He died on March 13.

Dr Emma Montgomery, a Consultant Nephrologist at the hospital trust, was asked by HM Senior Coroner Andrew Hetherington what impact the fall had on Bob.

She said he had chronic kidney disease and significant comorbidities and while the fall would have delayed his recovery, "separating it from the illnesses is very difficult."

Dr Montgomery described Bob as a "very pleasant gentleman".

The inquest heard the primary cause of Bob's death was urinary and chest sepsis, and that other conditions including chronic kidney disease, as well as his hip fracture, contributed to his death.

Mr Hetherington expressed his condolences to Bob's family and concluded that Bob died of natural causes contributed by an injury sustained by an accidental fall.

The coroner did not issue a prevention of future deaths report.