Judith Hughes

“The Inquest heard evidence about the Trust's use of the 'Close Observation Risk Assessment' (p1903 Medical Records Bundle). This requires scores to be attributed to several factors including 'inpatient falls during this admission' and 'previous falls'. The overlap between these two factors and what they actually refer to is unclear and confusing. This creates a risk that the overall score may be calculated incorrectly resulting in insufficient levels of observation, increased risk of falls and death.”