Andrew Hogg
27 Nov 2019 · Coroner Christopher Briggs · Manchester (South)
The coroner's concerns
1. escalating falls risk
“heard evidence of the sequence of falls which | have recounted above. While there may have been a falls assessment when [the deceased] first became resident at the home, there was no evidence before me of the nature and extent of that assessment. More particularly there was no evidence of any steps taken to review or reassess the falls risk following the falls [the deceased] had commencing in January 2019. There were some 7 falls before his final fall and it is a matter of concern that while each seems to have”
2. incomplete falls documentation
“Not all the relevant paperwork was completed following the falls”
3. lack of multidisciplinary falls service engagement
“There could have been engagement with other services such as the local falls clinic”
4. lack of preventive equipment deployment
“Consideration should have been given to using available equipment such as a sensor mat and”
5. inadequate electronic record updates
“Relevant information should have been updated onto the patient's electronic record”
6. absence of falls assessment policy
“There was no adequate falls assessment policy”
Responses
2019-0400-Response-from-Borough-Care-Ltd-Redacted.pdf ↗· Borough Care
Stated action
“process all home managers will be reviewing falls on our PCS (Person Centered Software) system on a weekly basis to ensure that falls are monitored more”