Recurance · prevention of future deaths reports
Pre-inquest brief
The earlier warning
David White · 11 Nov 2015 · Jacqueline Devonish, London Inner (North)
“(2) Nursing notes documented a risk of falls/mobilisation and action to be taken, but there was no supervision arrangement in place. One to one care had been in contemplation.”
What was promised
Stated action 1 · response to David White (11 Nov 2015) · stated timescale: none stated
“The safety briefing during nursing handover is now to include a verbal handover of the care plans for patients assessed as at risk of falls to alert incoming staff members as to the risk and care plan.”
judiciary.uk/wp-content/uploads/2015/11/2015-0437-Response.pdf
Stated action 2 · response to David White (11 Nov 2015) · stated timescale: none stated
“daily auditing of all nursing and falls risk documentation must be carried out.”
judiciary.uk/wp-content/uploads/2015/11/2015-0437-Response.pdf
Stated action 3 · response to David White (11 Nov 2015) · stated timescale: none stated
“Multidisciplinary Team meetings on Ward 9F have now been changed to earlier in the day to discuss patients and make effective action plans for patient at risk of falls.”
judiciary.uk/wp-content/uploads/2015/11/2015-0437-Response.pdf
3 further stated actions are listed on the full chain page.
What recurred
- 5 Oct 2023 · Iris Fordham · Graeme Irvine · Closely related · confidence 0.90 (high)
- 28 Oct 2024 · Ian Hegarty · Ian Potter · Closely related · confidence 0.90 (high)
The clearest link, quoted from both reports:
Earlier · Iris Fordham · 5 Oct 2023
“The consequence of (2) was that no falls care plan was completed.”
Later · Ian Hegarty · 28 Oct 2024
“That the plan of care put in place specifically to reduce the risk of falls for multiple patients was not followed.”
What happened next
No web check of the stated actions has been published for this chain.