Frederick Brooker

“Despite Mr [name redacted] sustaining multiple falls of increasing severity, no reasonable measures were taken by the Care Home staff to address the high risk of falling. Risk assessments were completed. The high risk was recognised, but there were no care plans to address the identified risk.”

“There were no steps taken by the Care Home staff to report the multiple falls to the London Borough of Redbridge who were commissioning Mr [name redacted] care. There was no referral to wheelchair services to consider whether the wheelchair provided for Mr [name redacted] was appropriate for him. There was no referral to occupational therapy for a review of Mr [name redacted] mobility. Following the falls, there was no evidence of Mr [name redacted] being encouraged to use his seat belt.”

“An investigation took place into a fall on the 15 March 2018. No further investigations were carried out by the home into the subsequent falls, including those falls resulting in injury. Senior staff were not, therefore, always aware of the circumstances of each fall. They were therefore not able to identify the optimum means of attempting to reduce the risk of further falls”

“There was reliance on the fact that Mr [name redacted] had mental capacity. This should not override the importance of care planning. Attempts should have been made to plan care to keep Mr [name redacted] safe. He should have been encouraged to follow the care plan and if he declined, this should have been clearly recorded. Following the falls, there was no evidence of a care plan to reduce the risk of falling from the wheelchair - or evidence of Mr [name redacted] being encouraged to comply with directions to help to”