Christiana Dawson
16 Oct 2024 · Coroner Tanyka Rawden · South Yorkshire (West)
The coroner's concerns
1. inadequate medication review
“Darnell Grange now have access to System One to be able to review prescribed medications”
2. inadequate fall referral
“All falls are now referred to the occupational therapy team at their local surgery”
3. inadequate care plan coordination
“All care plans are now reviewed with the local surgery and the resident's family”
4. exclusion of high‑risk residents
“Darnell Grange no longer admits those with a high risk of falls”
5. lack of agency staff training
“agency nurses are not trained on, or provided with, policies and procedures from Darnell Grange”
6. assumption of knowledge by agency staff
“The Court heard it was presumed from their nursing training they would know not to move a resident after a fall”