Edna Davenport
3 Apr 2020 · Coroner Joanne Lees · Black Country
A similar concern from this report was raised again 1 time later. See the linked reports.
The coroner's concerns
1. lack of emergency call system
“buzzer/alarm in the deceased room had been removed/disabled due to a previous incident where the deceased had attempted to place the cord around her neck”
2. unrecorded observations
“observations were not recorded as to when they actually took place or what was observed.”
3. door status not managed
“deceased preferred to have her bedroom door left open but this did not form part of her care plan”
4. inadequate risk assessment
“other resident suspected to have been the assailant was a new referral to the home and that there was a lack of information on her admission”
5. head injury not managed
“obvious signs of an injury to [the deceased]'s head in the form of the injury to her eye which resulted in bruising and swelling”
6. delayed medical review
“no medical review was sought until an ambulance was called on 29/11/19 when the deceased became unresponsive”
Linked reports
Closely relatedConfidence 0.90 · high
This report
“buzzer/alarm in the deceased room had been removed/disabled due to a previous incident where the deceased had attempted to place the cord around her neck.”
Later report
“There was no emergency bell/alarm or telephone in the residents' dining room.”
Responses
No published response was found on judiciary.uk.