A HOSPITAL ward manager in Carlisle has apologised after a mum of six ‘likely’ died because of a fall on the ward, which was not reported, an inquest has heard. 

Edna Sowerby, 71, of Kirkby Stephen, died on September 11, 2023 in Cumberland Infirmary in Carlisle after her condition rapidly deteriorated due to an abdominal bleed. 

She had suffered from chronic obstructive pulmonary disease (COPD) for 15 years, but, according to a statement submitted by her daughter, Wendy, Mrs Sowerby was a ‘hard-working, strong woman', who worked all her life until she retired aged 67. 

She said it was only in the last three years that the disease ‘slowed her down’, and she relied on an oxygen machine at home. 

The statement told that she had previously been placed on end-of-life care in February 2023 after giving herself carbon monoxide poisoning by overusing the machine, but after her oxygen was switched off in hospital, her daughter said: “We expected her to pass away quietly, but something amazing happened.  

“She woke up and asked what all the family were doing here, ‘I’m not going to die yet’.” 

Multiple visits to hospital that year due to low oxygen levels led to her admission on August 22, 2023 due to chest pain and shortness of breath. 

Cardiac, gall bladder, and liver abnormalities were detected, and on August 29, Mrs Sowerby was transferred to Beech Ward, where on September 7, she tested positive for Covid-19 and was moved to a single room. 

According to the statement of a consultant in respiratory medicine at the hospital she remained ‘clinically stable’. 

On the evening of September 10, nursing staff noted that Mrs Sowerby was becoming increasingly unwell, with vital signs showing rapid deterioration, and staff noticed bruising on her lower abdomen and bleeding from her urinary tract. 

She was taken for a CT scan and x ray, which showed an undisplaced (indicating recent) pelvic fracture, which had caused a blood collection in her abdomen. 

She reported to staff that she had fallen the previous day (September 9), and was picked up by a man wearing white, though a fall was never recorded. 

Family members told Assistant Coroner for Cumbria Ms Margaret Taylor, that Mrs Sowerby had told them on the phone ‘just after lunch’ on September 9, about the fall. 

The family member said that they then reported this to ward staff, but this was never acted on, or recorded. 

Beech Ward manager, Caroline Lodge, was present in court to answer questions posed by Ms Taylor about the events leading up to Mrs Sowerby’s death. 

Ms Lodge admitted that with Mrs Sowerby being in a side room rather than a multi-patient bay due to Covid, it was more difficult to give constant attention to her, but that risk assessments had been performed, and she had been identified as a risk. 

She also said that it was not always the case that falls risk assessments are completed twice daily with every patient as per protocol due to levels of staffing and how busy the ward is. 

She confirmed that three male staff were working on the ward that day, who all wore white. 

Ms Lodge said that a number of concerns had been found during a Trust investigation, including that recording of staff actions was not as detailed as it should have been that day, and that there had been a delay and lack of training in the use of a system used to enter and record incidents. 

She outlined a number of actions that the Trust had taken as a result of the investigation. 

Ms Taylor said: “This witness can’t say any more, other than that once the fall had happened, it should have been reported.  

“All the witness can do is apologise as it's not the way she’d expect her staff to have acted.” 

Ms Taylor accepted the medical cause of death offered as a haematoma, caused by trauma due to a pelvic fracture. 

She also said during the hearing: “On the balance of probabilities, I can say that she had a fall and been taken back to bed.” 

Addressing Mrs Sowerby’s family, Ms Lodge said: “I’m so sorry I can’t answer for the actions of my staff on that day.”