Henry Honour

1. 1. falls on ward

   “Between January 2017 and April 2017 five deaths occurred on Cambridge Wards at William Harvey Hospital. Common to each was the fact that the death was caused as a result of a fall on the ward in circumstances where falls risk assessments were either inadequate, incomplete, not reviewed or not enforced.”

2. 2. falls risk assessment

   “In respect of Mr [name redacted] the falls risk assessment completed on admission was at best perfunctory, as were subsequent reviews which did not rectify earlier errors or recognise the need for precautionary measures to be taken when Mr. [name redacted] should have been nursed in an observable bed with a falls alert and hip protectors in light of the risks posed.”

3. 3. bedrail risk assessment

   “The bedrail risk assessment was difficult to interpret in light of the falls risk assessment, bed rails were utilised when they should not have been.”

4. 4. falls risk assessment

   “The falls risk assessment was not updated post fall and no protective measures were put in place.”

No published response was found on judiciary.uk.