Bridget Gormley
7 Feb 2023 · Coroner David Reid · Worcestershire
A similar concern from this report was raised again 1 time later. See the linked reports.
The coroner's concerns
1. lack of updated falls risk assessment and care plan
“During the course of her evidence, the inquest heard that Mrs. [name redacted] had suffered four falls at Latimer Court between 31 March 2022 and 4 April 2022, and a further four falls between 12 July 2022 and 17 July 2022. Latimer Court's registered home manager, [REDACTED], conceded in her evidence that neither Mrs. [name redacted] Risk Assessment document, nor her Falls Care plan document were updated following any of these falls, and that they should have been so updated”
2. staff misunderstanding of documentation duties
“[REDACTED] was unable to explain why these important documents had not been updated as they should have been by staff at Latimer Court. There is therefore concern that staff at Latimer Court did not, and may still not understand their duties and responsibilities to update residents' documentation in such circumstances”
Linked reports
Closely relatedConfidence 0.80 · moderate
This report
“Latimer Court's registered home manager, [REDACTED], conceded in her evidence that neither Mrs. [name redacted] Risk Assessment document, nor her Falls Care plan document were updated following any of these falls”
Later report
“It was noted in the evidence, that the observation scores taken for Mr [name redacted] following his fall had not all been recorded in Mr [name redacted] care notes.”
Responses
2023-0114-Response-from-Barchester-Healthcare-.pdf ↗· Barchester Healthcare
Stated action
“Following this very sad incident we have made a number of changes to the provision of care and services at Latimer Court, and these have been adopted across the organisation in other services and divisions where appropriate”
Stated action
“At Barchester Healthcare, all residents care plans are reviewed by the senior carer in a residential home every month or when anything significant changes in their care or support requirements such as a fall”
Stated action
“Following any fall or found on floor incident the falls risk assessment should be reviewed and the falls diary completed. The falls care plan should be updated accordingly and referrals made as appropriate”
Stated action
“Barchester Healthcare have also now developed and introduced a specific Post Falls Assessment Tool to aid with the assessment of a resident following a fall or found on floor incident”
Stated action
“As part of the lessons learnt as identified by the General Manager at Latimer Court it was highlighted that staff required further training from the organisation's Clinical Development Nurse in the approach to and completion of documentation”