Etheline De-Gale
16 Feb 2017 · Coroner Ian Pears · Bedfordshire and Luton
The coroner's concerns
1. vague care plan leading to inadequate assistance
“The care plan was too vague to be of assistance to the carers. The carer | understood that the deceased required 2 carers to assist her to the | commode, but interpreted that as being limited to walking across the floor, but not sitting up in bed with the sides removed or sitting on the side of the bed”
2. lack of guidance for risk assessment
“The Deputy Manager indicated that the carer should have undertaken a risk assessment, but could offer no guidance on how that was to be achieved.”
3. insufficient staffing compromising resident safety
“There were only 2 members of staff on duty, which compromised the safety of other residents when a resident required 2 members of staff to assist.”
4. insufficient staffing compromising best interests decisions
“There were only 2 members of staff on duty, which potentially could compromise decisions made in the best interests of a resident. One carer accompanying a resident to hospital would clearly create a problem and that could potentially be seen as a basis for not admitting a resident to hospital.”
5. paramedic recommendation ignored
“The recommendation of the paramedics appears to have been ignored.”