Edward Mallaby

“1. There was no clear policy with the handling of residents' personal property which may be hazardous. In particular, if the television could not be immediately fitted or stored securely, then the family should be told to arrange another time for it to be Civic”

“Ifa sensor mat was fitted it then it did not activate to alert staff that the deceased was out of bed. 3”

“Staff only discovered the deceased "with the TV Box on the top of his legs" on a routine check rather than by a sensor mat or personal alarm call.”

“Although the deceased had a falls risk assessment, it was not clear whether he was subject to hourly or half hourly observations, or whether the door to his room was to be open or not.”

“There appeared to be no rapid learning exercise to ensure that other residents were not at any ongoing risk.”

“A full review of policy and procedure with associated training was apparently underway but without a deadline for completion.”