A CARE home resident in Carlisle died in hospital after a spinal cord injury went undetected for four days, an inquest has heard

Michael Geddis, 69, died in the Cumberland Infirmary on March 17, 2024, after suffering a series of falls over a four-day period in Greystone House care home, after the last of which he went into cardiac arrest.

In a series of statements submitted to Cockermouth Coroner’s Court, care home staff outlined the timeline of events from March 13 that led to Mr Geddis’ death.

He was diagnosed with bipolar disorder in 2019, and had been assessed in the care home as being a 'low risk' of falls.

However, when a staff member knocked on his door to give him his night medication on the evening of March 13, she heard Mr Geddis shout that he was on the floor.

She said he had 'no apparent injuries' but complained of a pain in his back, and that the bathroom floor was wet.

He fell again at 3.45am on March 14, and said he hit his head on the radiator.

The statement said that Mr Geddis had a 'small bump' on his head, that he 'seemed unable to keep himself up'.

Staff called Cumbria Health On Call (CHOC), as they were concerned that his behaviour was 'erratic', was 'not his usual self', and didn’t usually fall.

Paramedics were called, arriving at 7.20am, but decided after checking Mr Geddis that he did not need to go to hospital.

Assistant Coroner for Cumbria, Dr Nicholas Shaw, comment that it was 'very reasonable' for care home staff to seek support from doctors after two falls.

Care home manager Rebecca Purdham said in a statement that Mr Geddis was presenting 'very differently', was concerned he may have an infection or head injury, and requested a GP assessment, which raised concerns that led to another ambulance being called.

While waiting, he was in the dining room, and told staff his neck and head were hurting, and 'dropped to the floor' as the ambulance arrived.

A CT scan and chest x-ray were carried out in hospital to rule out any underlying issues, but no new injuries were detected.

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Dr Shaw said there was 'nothing in the way he was mobilising to alert them', and he was discharged back to the home on March 16.

A care assistant's statement said that on his return, Mr Geddis was acting 'very out of character', and was 'wheeling himself around during the night'.

He was found on the floor in the dining room at 3.45am on March 17.

He was assessed by paramedics who again deemed it safe for him to remain in the home.

A senior care assistant said in a statement that at 11.50am on March 17, Mr Geddis had gone out for a cigarette but minutes later, staff found him on the dining room floor.

An ambulance was called at 11.53am, and while Mr Geddis was at first responding to questions, he began to deteriorate, and went into cardiac arrest as the ambulance arrived at 12.20pm.

A scan of his neck in hospital revealed a possible spinal fracture and damage to Mr Geddis' spinal cord.

He continued to deteriorate and was treated palliatively.

Mr Geddis was pronounced dead at 6.20pm.

Dr Shaw said: "I suspect he suffered a cervical spine fracture on the evening of March 13 when all this began and that hasn't been recognised, and that has led to his death.

"I can understand why it hasn’t been recognised.

"If you have an unstable fracture that high up, it will be potentially wobbling around, and you have to just press a bit on the spinal cord it can cause paralysis and collapse.

"Someone comes to examine him, he’s lying down, the pressures off, and his observations are all normal."

Dr Shaw accepted the cause of death offered as spinal shock, caused by a cervical fracture, and concluded that Mr Geddis' death was accidental due to his original fall.