Edna Bulmer

1. 1. inconsistent risk identification

   “There did not appear to be a clear identification of the level of risk of Mrs. [name redacted] falling made within Dovecote Lodge records. In one section Mrs. [name redacted] is described as very high risk, elsewhere she is described as high risk.”

2. 2. delayed implementation of fall prevention measures

   “The measures identified within the Personal Risk Assessment to minimise risk were not implemented (provision of mat and pendant) until several days after Mrs. [name redacted] arrival, after a number of incidents had occurred.”

3. 3. lack of post-incident risk assessment review

   “There did not appear to have been a review of the risk assessment after further fall incidents. Is there a system in place which requires a further review of the Personal Risk Assessment? If so, who has responsibility to undertake such a review? If such system does exist has it been effectively communicated to all staff members, including 2”

No published response was found on judiciary.uk.