STAFF shortages at the Hospital contributed to the death of an 86-year-old woman who was supposed to have constant one-to-one care, but fell while a health care assistant was alone supervising her, an inquest heard.
Denise Gwendoline Harris, who was known as Denny, died on 17 December 2025 in Jersey Hospital.
During an inquest into her death yesterday, it was heard that an external serious incident report questioned the guidelines for enhanced and one-to-one care.
It highlighted the Hospital had been under-staffed at the time and that there needed to be greater guidance on what happens when a one-to-one carer goes on break and a need for increased education on how to respond to a patient falling.
The review also pointed out that bank staff were not paid for education and training – leading to few of them completing the training.
Mrs Harris was admitted to hospital on 2 November with chest and urinary tract infections, and, although she recovered, she suffered from acute delirium and was placed on a significant restriction of liberty and required continuous one-to-one care.
The inquest heard that the staff member assigned to her had gone on break, and the health care assistant who was watching the ward went to sit near Mrs Harris while she processed notes.
In that time, the inquest heard, Mrs Harris got out of bed and fell. The health care assistant jumped up to help, but slipped and also fell.
Despite having no visible injuries, a CT scan showed bleeds to Mrs Harris’s brain. She deteriorated in the next weeks, the inquest heard, and died on 17 December 2025 as a result of her injuries.
David McKenna, who was appointed after Mrs Harris’s death as associate chief nurse for harm-free care, said that on the night she fell, the ward had been home to six patients on serious restrictions of liberty and three patients needing one-to-one care. Two patients were at “high risk of absconsion”, he said.
He said he had focused on falls and pressure injuries so far and that projects piloted in other wards had reduced the number of falls by more than half. He added that some training had been made compulsory for any staff, including bank staff.
The hospital’s record-keeping was also criticised, with a mix of digital and paper-based systems used – meaning Mr McKenna had not “been able to work out” where nurses were on the night.
He said: “When you look at it… it looks bad, to be quite honest…
“I do really apologise for that.
“I will be working on this to do something different, so that this doesn’t happen again. I am really sorry.”
According to relatives of Mrs Harris who spoke at her inquest, she was in good health for her age and had been on a trip to London just months before her death.
She was described by her daughter Sarah as a great cook who loved animals and loved entertaining, and that her mother would be remembered for the “love, laughter, kindness and strength she gave to us all”.
“Our home was always a hub of activity and all were welcome,” she continued, adding that “all were welcome and it would often turn into quite a party”.
Assistant coroner Dr Deryn Evans described Mrs Harris as “quite a remarkable woman”.
Born in Lincoln in 1939, she met her husband Ronnie while on holiday in Jersey, and they lived in Jersey, Portsmouth and Spain together, returning to Jersey to be near their grandchildren.
Tabetha Darmon, director of nursing, AHP’s, clinical governance and quality, said: “I would like to extend my sincere condolences to Mrs Harris’s family and loved ones. Following this case, we undertook a review to identify learning to reduce a similar incident happening in the future and to reduce the severity and frequency of patient falls.
“Since that investigation, HCJ has appointed a falls and frailty nurse and a harm-free nurse who are reviewing the processes related to falls management within the hospital to ensure alignment with the Royal College of Physicians best practices guidance. Furthermore, we are reviewing our arrangements to ensure that we consistently deliver one-to-one enhanced therapeutic observations of care when this is required.
“I would like to reassure Islanders that HCJ remains committed to the continuous improvement of our services, to ensure the highest standards of care for our patients.”
