Elsie Brown
4 Dec 2015 · Coroner Stephanie Haskey · Nottinghamshire
The coroner's concerns
1. lack of falls risk assessment
“There was no falls risk assessment nor bed rails assessment in place for Mrs [name redacted], nor was her mental capacity assessed”
2. incomplete care plan
“Mrs [name redacted] care plan was incomplete, unsigned, undated and never reviewed, despite Mrs [name redacted] falling from her bed on 8" March 2015”
3. lack of referral to falls team
“No referral was made to the Falls Team nor (by Langwith Lodge) to Derbyshire Community Health as regards the question of bed rails”
4. unclear responsibility for bed rails assessment
“There was a lack of clarity as to where the responsibility for an initial bed rails assessment lay”
5. insufficient auditing process
“There was an insufficiently robust auditing process, in that the omissions were not identified by Langwith Lodge nor by Your Health Ltd”
6. lack of incident handover and recording
“Mrs [name redacted] fall on 23 March 2013 was not handed over, nor recorded nor reported, and there was a lack of clarity amongst staff as to where responsibilities for these matters rested”