Jennifer Rackley
6 Jun 2023 · Coroner Heidi Connor · Berkshire
A similar concern from this report was raised again 1 time later. See the linked reports.
The coroner's concerns
1. bed in centre of room with single sensor mat
“It seems likely that [the deceased]'s bed was in the centre of the room, with one sensor mat only, despite a high falls risk.”
2. lack of documented investigation
“Evidence was given that an investigation was carried out - despite no written document/ record of this being made - and the manager being unable even to name the care staff involved in the incident.”
Linked reports
Closely relatedConfidence 0.80 · moderate
This report
“Evidence was given that an investigation was carried out - despite no written document/ record of this being made - and the manager being unable even to name the care staff involved in the incident.”
Later report
“The Deputy Manager who had drafted this handover document, was also responsible for the care home's own internal investigation into Mrs. [name redacted] fall. That internal investigation failed to highlight the deficiencies in the handover document, and the handover document itself was not disclosed to the Coroner's Office until the final inquest hearing was underway.”
Responses
No published response was found on judiciary.uk.