Mystery of how patient got onto roof

AN elderly hospital patient suffering from dementia made his way past locked doors, ladders and stairs to gain access to a roof where he died, an inquest heard.

AN elderly hospital patient suffering from dementia made his way past locked doors, ladders and stairs to gain access to a roof where he died, an inquest heard.

Thomas Pilfold, 76, died of pneumonia on the roof of West Suffolk Hospital, Bury St Edmunds, after wandering from the ward where he was being treated.

Intensive investigations and searches by police, hospital staff and search and rescue crews failed to locate Mr Pilfold for two days after he went missing in February.

The inquest in Bury St Edmunds heard yesterday Mr Pilfold, a former heavy drinker, was originally admitted to hospital with dehydration, vomiting and diarrhoea, but later treated for anaemia, dementia and alcohol-related tremors.


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After appearing unsteady on his feet, he recovered some movement after treatment and began to wander away from the ward, once being found walking in snow in the hospital car park wearing just slippers and pyjamas.

Mr Pilfold, who lived in Haverhill, went missing for the last time at about 5pm on Saturday, February 8.

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He was not found until Monday morning, when his half-naked body was discovered by a contractor, next to a heating vent on the hospital roof.

Mr Pilfold's pyjama bottoms, dentures and slippers were found close to his body and his cause of death was later found to be aspiratory pneumonia, which medical staff said was common for sufferers of dementia.

David Gregory, of the Health and Safety Inspectorate, said the hospital had failed to take appropriate action to prevent access to the roof after a contractor's ladder had been found unattended and unsecured.

Hospital work superintendent, Terrence Bird, said although it seemed unlikely Mr Pilfold could have negotiated ladders and scaffolding, other routes had been blocked by locked doors.

Nichole Day, the hospital's Director of Nursing and Community Relations, told the inquest: “After the incident we undertook a root cause analysis and developed an action plan and written procedure for management of missing persons.

“We have reviewed our code of conduct for contractors and placed greater emphasis on security and inspections of construction sites.”

The jury returned a verdict of death by natural causes and coroner Dr Peter Dean said how Mr Pilfold had come to be on the roof and how he had eluded the search parties would remain a mystery.

Speaking after the inquest, a spokesman for West Suffolk Hospitals Trust said: “This tragic case shocked and saddened everyone who was involved in the care and search for Mr Pilfold.”

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