Desmond died on Boxing Day 2024 after waiting one week for a transfer to hospital despite having a known bleed on the brain and collapsing twice into unconsciousness following a fall. The coroner today concluded his cause of death was an acute brain bleed due to a fall in hospital.

The family of a much-loved husband, father of three, grandfather of eight and great-grandfather of 12, have received some answers into his death after the Coroner said there were some nursing failures including him not being admitted to the most suitable ward, not having regular neuro observations performed and no fall care plan put in place, despite him being at risk of a fall.

84-year-old former RAF sergeant Desmond Stewart fell at his home in Watford on 28 November 2024. Initially he felt okay but on 1 December 2024, he woke up with a severe headache. He went to Watford A&E on 1 December 2024 where a scan of his head showed a haematoma (bleed on the brain). His case was referred to the neurosurgical team at St Mary’s Hospital, London, for advice. Watford Hospital were told by St Mary’s to admit him for 24 hours for observation. After 24 hours, his observations were noted to be stable, and he was deemed safe for discharge.

Desmond tried to carry on as normal once home, but his headache continued to worsen.

Just over a week later (11 December 2024), as he was still suffering from the headache, which was worsening, he went to his GP who advised not to worry but to seek medical advice should he deteriorate.

As his headache was no better the next day, and he was also now suffering from speech problems and confusion, Desmond went once again to Watford A&E, where a scan of his head revealed the bleed on the brain had grown in size and his blood pressure was 199/66 mm Hg (the average healthy reading is around 120/80 mm Hg.) He was referred once again to St Mary’s for advice who advised that Desmond be transferred to them on a “non-urgent” basis - once a bed had been confirmed. He was admitted into Watford hospital in the interim.

After being admitted onto the ward (which wasn’t until 13 December in the late afternoon), a falls care plan was not completed despite a falls risk assessment noting that Desmond was at risk of a fall due to his age, the fact he had suffered a fall recently and his unsteady walking. His high blood pressure also went untreated until later that evening when medication was administered.

Furthermore, in the evening of 13 December, Desmond was left unsupervised by staff and upon mobilising himself independently, he fell. Immediately following the fall, his condition deteriorated and he fell unconscious. He underwent another scan which revealed he had suffered a second acute brain bleed. St Mary’s Hospital was contacted again for advice and the team at Watford were told to monitor Desmond and manage him on the ward.

Desmond started to regain some degree of consciousness on 17 December and showed some signs of improvement by 20 December. But Desmond unfortunately fell unconscious again on 21 December, whilst still at Watford Hospital. He was re-scanned on 24 December, again still at Watford, which again confirmed the bleeding on the brain was ongoing, something which staff already knew. When Desmond was eventually transferred to St Mary’s, which wasn’t until Christmas Day, despite neurosurgical intervention, he continued to deteriorate and sadly passed away the next day.

The Coroner concluded today that Desmond was not admitted onto the most suitable ward for his injury, there was a lack of neuro observations performed and despite Desmond being at risk of falls, no falls care plan was put in place. Whilst the Coroner did conclude that it wasn’t clear whether these matters contributed to his death, he did conclude that the fall (which caused him to suffer the secondary brain bleed) caused his death.

Nadia Valentine, clinical negligence specialist solicitor with JMW, who is acting for the family, said:

“It seems that the hospital staff underappreciated the severity of Desmond’s situation, the urgency of it and the need for action; there was a lack of prioritisation, focus, understanding and management of the issues at hand, leading to errors which sadly resulted in poor care. We intend to explore the Coroner’s conclusions further.”

His widow Jeanette said:

“In the weeks leading up to his death, I was very concerned there were several missed opportunities, delays, poor supervision and clinical errors which I believe amounted an extremely poor overall level of care and significant failings in Desmond’s treatment.”