THE death of a 93-year-old man who suffered a series of falls in hospital "was contributed to by neglect," a coroner has concluded.

Alan Jones fell at least six times during his three-week stay at Nevill Hall Hospital in Abergavenny.

Partly due to his Alzheimer's, the retiree from Gilwern had been assessed as being in the highest-risk level for falls, meaning he should have been under constant nursing supervision.

But Caroline Saunders, the senior coroner for Gwent, said evidence showed it was "clear" throughout Mr Jones' time in hospital that Ward 4/1 had been "understaffed".

She said "nurses were expected to get on with as as best as they could" amid a lack of staff cover or a coordinated falls management plan between medical teams.

Mr Jones was often more "agitated" at nighttime and tended to get out of bed - but nurses' requests for an extra staff member to supervise the 93-year-old often went unfulfilled, the inquest was told.

His final fall happened in the middle of the night, when he should have been under one-to-one nursing supervision.

Staff had requested an extra nurse for that shift, the inquest was told, but nobody had arrived.

Aneurin Bevan University Health Board says it has taken "corrective actions" to address the issues raised by Mr Jones' death, having conducted a Serious Incident investigation into the circumstances of his death and the care he received.


The inquest heard from a ward nurse who, while he had been keeping an eye on Mr Jones that night, noticed another patient out of bed and about to fall.

Tragically, as he helped steady that patient and guide him towards the bathroom, he heard a crash, turned around, and saw Mr Jones face down on the floor.

The 93-year-old suffered a head injury and his condition deteriorated. He died the following day, on November 14, 2019.

Ms Saunders said there had been "no multi-disciplinary approach" to the management of Mr Jones' risk of falling - which she said was "clearly in the highest category".

"There's no evidence that nurses, doctors, physios and pharmacists met together to discuss how [Mr Jones'] problems could be managed," the coroner told the inquest.

She said the series of falls "demonstrated a complete failure of the falls prevention strategy at Aneurin Bevan University Health Board".

The coroner also raised concerns that Mr Jones' care plan had not been updated after some of his falls, and she questioned whether there had been a proper assessment as to whether Mr Jones required bed rails - a safety issue for restless patients who are at risk of falling.

Recording a narrative conclusion, Ms Saunders said she would be writing to Aneurin Bevan University Health Board (ABUHB) about the "failure of a proper multi-disciplinary care plan" for Mr Jones.

She said she would also be raising with ABUHB concerns about the understaffing of wards.

Though it fell outside the scope of the inquest, the coroner said she would also raise with the health board queries regarding its policy on patient observations, as well as seeking confirmation Mr Jones' death was brought to the attention of the Health and Safety Executive.

A spokesman for Aneurin Bevan University Health Board said: “Our thoughts remain with the family of Mr Jones.

"The health board has conducted a thorough Serious Incident investigation into the care that Mr Jones received.

"We have met with the family and shared the findings of our investigation fully and openly with them.

“The health board has already taken corrective actions and steps to address issues raised through our investigation.”