Woman died in Derriford hospital after push by another patient

An 89-year-old woman died at a Devon hospital after being pushed to the ground by a fellow patient who had carried out similar attacks, a report has found.

Mary Pomeroy suffered fractures after the incident at Plymouth’s Derriford Hospital and died 12 days later on March 15 2022.

Coroner Nicholas Lane’s report found she died as a direct result of the push from the patient who had “psychiatric, behavioural and cognitive difficulties”.

He said the patient was “not being closely supervised in the ward” and issued a Prevention of Future Deaths report to the hospital’s trust and chief nursing officer.

The inquest into Mrs Pomeroy’s death was told the other patient had done the same thing to another person on the ward two days before.

The same patient had also been involved in a number of incidents where he had used physical force on staff members on the ward the month before.

The coroner said a hospital investigation report concluded that it was “a rare and devastating accident which could not have been foreseen”.

But a matron said the hospital’s report was incorrect and if enhanced care and observation had been in place, the incident should have been prevented.

Mr Lane’s report found there was a “lack of assessment and management” of the patient who pushed Mrs Pomeroy and this “materially contributed to the incident occurring and therefore to Mary’s death.”

He said the hospital needed to “identify concerning matters when carrying out internal investigations” and take steps to try and learn from serious incidents when they occurred.

He said that if these steps were not taken, there were “obvious, significant and continuing risk of future deaths occurring”.

The trust has 56 days to respond to the coroner’s report containing details of proposed action or why no action is being taken.

The hospital’s trust has been approached for comment.