THE Health and Safety Executive has served an improvement notice on health chiefs after the death of a man who fell in the hospital where he was once Medical Director.

And an internal review carried out by Betsi Cadwaladr University Health Board also confirmed there had been failings leading to the death of Mervyn Rosenberg.

Mr Rosenberg, 86, died at the Maelor Hospital, Wrexham, on May 9, 2020, four days after being admitted following a fall at his home in Station Road, Chirk.

The retired surgeon’s wife Katherine told an inquest in Ruthin that she repeatedly told hospital staff that he had Parkinson’s Disease and was unsteady on his feet even when using a walking aid.

He was admitted to Erddig Ward but while there was found on his knees, having fallen.

Two days later, on May 7, he was transferred to Morris Ward, but the inquest heard that although his notes referred to his being a falls risk there was no mention of his having fallen while in hospital.

That night another patient raised the alarm when Mr Rosenberg fell out of bed and staff found him lying against a wall with facial injuries.

His condition deteriorated and he died in the early hours of the 9th. The cause of death was given as a severe bleed on the brain, the result of the fall.

Mrs Rosenberg, a former nurse, lodged a complaint about the failure to pass on information and poor communication with the family when they were unable to visit the hospital because of the Covid-19 restrictions.

The inquest heard that Mr Rosenberg’s bed was in the bay furthest away from the nurses’ station and nurse Amanda Morris said that if the dayshift staff had been told about the hospital fall he would have been placed under closer observation.

The Ward matron Rebecca Jones, who was not involved in Mr Rosenberg’s care, said: “I would have expected the ward sister to have asked for more information at handover.”

David Pojur, assistant coroner for North Wales East and Central, read the letter sent by the Health and Safety Executive to the chairman of the Health Board containing the improvement notice.

It was prompted by problems not only in Mr Roseberg’s case but in a similar case involving a woman who fell at Ysbyty Gwynedd.

The Executive called for improvements in carrying out risk assessments on patients known to be at risk of falling, the passing on of information when patients are transferred from one ward to another, and in the training of staff.

The Board is not appealing against the notice but has until next September to formally respond.

However, Erin Humphreys, the Maelor Hospital’s head of nursing, said a great deal had already been done to tackle the issues raised in the HSE letter, and the improvements were already producing results across the Board’s region.

“There has been a reduction in the number of incidents,” she said.

Recording a conclusion of accidental death, Mr Pojur said it was clear that different measures would have been taken if the day staff had been made aware of Mr Rosenberg’s previous fall.

“But, having heard of the improvements in training and handover notes being rolled out across the Health Board area I don’t think there is a risk of future deaths,” he added.