June Peel

“There was a failure to record the injury from the body map in the daily communication records both on 3rd [the deceased] and 6th [the deceased], and a failure to pass that information on at handover (or to document that the information had been passed on). This led to a period in which [the deceased] was being turned on a 2 hourly basis with a displaced femur fracture.”

“There was a failure to recognise that medical attention was required for [the deceased] from at least 3rd [the deceased] 2022, notwithstanding all personal care being conducted by the healthcare assistants.”

“There was a failure to follow the care plan by the healthcare assistants. There has been no investigation done to identify whether this is a condoned or common practice within the home.”