Kathleen Devine
22 Nov 2017 · Coroner Timothy Brennand · Manchester (West)
The coroner's concerns
1. lack of observation recording
“The failure of staff to record observations between 6.30am and 8.30am”
2. falls mat and sensor removal
“The removal and unplugging of a falls mat and sensor in the room of a resident with high risk falls who was awake, unsupervised and unobserved”
3. inadequate handover instructions
“The quality and extent of handover instructions to agency staff”