Missed falls risk assessment
Stepping Hill Hospital received 2 coroners' reports about this hazard between 17 Feb 2014 and 26 Aug 2016.
They came from 2 different coroners. A similar concern was raised again 1 time after the first warning.
A published response was found for 1 of the 1 earlier reports, stating 2 specific actions.
The story, report by report
Spacing grows with the time between reports.
“Despite training being in existence in relation to the carrying out of Falls Risk Assessments there was a missed opportunity throughout the time Mrs [name redacted] was in hospital for this to be carried out.”
Original on judiciary.uk ↗ Stepping Hill Hospital responded, stating 1 specific action.Response (PDF) ↗
“We have instigated an escalation process whereby, if any equipment cannot be located within the mmediate ward environment, staff must contact the senior nurses on 'professional cover' for the Business 3roups by bleep in the first instance to assist in locating the equipment. Should the bleep-holder be unable '0 resolve the problem, this is to be escalated to the hospital site manager who will either locate the squipment or assist in the re-assessment of those currently in use across the hospital”
- 2 years 6 months laterIdentical hazardConfidence 0.90 · higha different coroner
“if, from the falls risk assessment, there were concerns as to Mrs [name redacted] mobilising in and out bed and/or in and out of her chair and her stability then these would have been highlighted in the nursing notes/care plan and discussed at any handover”
Original on judiciary.uk ↗ Repeated from the earlier report:fallsrisk
Stepping Hill Hospital responded, stating 1 specific action.Response (PDF) ↗
“Please see attached the June ward newsletter for your information (page 2). In August 2016, | can confirm that the findings of the Coroner's Inquest was shared on Ward E2 and attention drawn to the need for fall risk assessments to be reviewed when a bed-bound patient starts to sit out in a chair. Please see attached the August ward newsletter for your information (page 2).”
Stated timescale: August 2016
- All reports to Stepping Hill Hospital
Each row is one judged link between an earlier and a later report. Open a row to read both quotes, found word for word in the originals.
2014 → 2016Maureen Flynn2 years 6 months after Laura Hill · different coronerIdentical hazardConfidence 0.90 · high
Identical hazardConfidence 0.90 · highBoth reports highlight that a falls risk assessment was not completed, leaving staff unaware of the patient's risk. This omission prevented proper communication and planning for fall prevention.
Laura Hill · 17 Feb 2014
“Despite training being in existence in relation to the carrying out of Falls Risk Assessments there was a missed opportunity throughout the time Mrs [name redacted] was in hospital for this to be carried out.”
Original on judiciary.uk ↗ Maureen Flynn · 26 Aug 2016
“if, from the falls risk assessment, there were concerns as to Mrs [name redacted] mobilising in and out bed and/or in and out of her chair and her stability then these would have been highlighted in the nursing notes/care plan and discussed at any handover”
Original on judiciary.uk ↗
Stated action
“We have instigated an escalation process whereby, if any equipment cannot be located within the mmediate ward environment, staff must contact the senior nurses on 'professional cover' for the Business 3roups by bleep in the first instance to assist in locating the equipment. Should the bleep-holder be unable '0 resolve the problem, this is to be escalated to the hospital site manager who will either locate the squipment or assist in the re-assessment of those currently in use across the hospital”
Stated action · timescale: August 2016
“Please see attached the June ward newsletter for your information (page 2). In August 2016, | can confirm that the findings of the Coroner's Inquest was shared on Ward E2 and attention drawn to the need for fall risk assessments to be reviewed when a bed-bound patient starts to sit out in a chair. Please see attached the August ward newsletter for your information (page 2).”
- Each report's concerns were extracted by Nemotron 3 Nano on Nebius Token Factory, each with a quote copied from the report.
- Concerns from reports to Stepping Hill Hospital at least six months apart were compared by meaning (Qwen3 embeddings) and wording (TF-IDF).
- The closest pairs were judged by Nemotron 3 Super with reasoning on. Only identical or closely related, with confidence of at least 0.70, are shown.
- Every quote was checked by code as an exact substring of the original text. Names of staff and family are redacted, and the deceased are named by report title only.
| Link | Meaning | Wording | Judge | Coroner |
|---|---|---|---|---|
| 2014 → 2016 | 0.80 | 0.07 | Identical · 0.90 | different |
Judge model: nvidia/nemotron-3-super-120b-a12b. How Nemotron did the work · Full methodology.
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This shows that a similar concern was raised again after an earlier report. It does not say why, and it is not a finding about any organisation or person. To report an error, see the corrections route.