Nicholas was admitted to Ealing Hospital on 5 October 1998, having suffered an alcohol related fit. While he was in the accident and emergency department, he fell from the trolley injuring his right eye.

Nicholas was admitted to a general medical ward and at approximately 08:30 on 6 October 1998. He suffered a further fall injuring the left side of his head. He underwent a CT Scan within approximately 20 minutes of the accident. The scan was reported as showing no abnormality.

Between 7 October and the morning of 13 October, Nicholas' condition deteriorated. He remained confused (despite the withdrawal of sedatives to prevent further fits), became doubly incontinent and spent most of the time asleep.

A further fall was recorded on the fluid balance chart of 10 October 1998 but no accident report was filed. Neurological observations were not performed on a regular basis and were terminated on 10 October 1998. No neurological assessments were undertaken by the medical staff after 6 October 1998.

At approximately 09:00 on 13 October 1998 Nicholas' wife complained to the nursing staff that her husband was unrousable.

When Nicholas was seen on a ward round a couple of hours later, he was discovered to be unconscious.

A CT Scan confirmed that Nicholas had suffered extensive intra-cranial bleeding and there was a fracture of the skull in the left temporo-parietal area.

Following consultation with the Regional Neurosurgical Centre, it was advised that no treatment could be offered and Nicholas suffered a respiratory arrest and died later that day.

Expert evidence was obtained from a consultant in general medicine who confirmed that the management of Nicholas on the ward had fallen below the required standard.

There had been a failure to investigate Nicholas' ongoing confusional state after 6 October by means of regular neurological observations, examinations and repeat scanning.

However, both the expert in general medicine and an expert in nursing care agreed that no criticism could be made of the failure to prevent Nicholas suffering the falls both in the accident and emergency department and on the ward.

Neurosurgical evidence confirmed that if appropriate reviews had been undertaken, Nicholas' deterioration would have been determined and scanning would have revealed raised intra-cranial pressure.

Nicholas would have been referred to a Regional Neurosurgical Centre where action could have been taken to relieve the raised intra-cranial pressure thereby preventing Nicholas' final deterioration.

That being said, Nicholas would have suffered permanent serious neurological deficit as a result of injuries sustained following the second fall.

We advised the family of the difficulties on the issue of causation. A Part 36 Offer was made and following negotiations, Nicholas' widow accepted £12,000 in full and final settlement of the claim.

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