Laura Hill
17 Feb 2014 · Coroner Joanne Kearsley · Manchester (South)
A similar concern from this report was raised again 1 time later. See the linked reports.
The coroner's concerns
1. missed falls risk assessments
“Despite training being in existence in relation to the carrying out of Falls Risk Assessments there was a missed opportunity throughout the time Mrs [name redacted] was in hospital for this to be carried out. There was no assessment on her admission to Ward C3 nor when she was transferred to Ward B6.”
Linked reports
Identical hazardConfidence 0.90 · high
This report
“Despite training being in existence in relation to the carrying out of Falls Risk Assessments there was a missed opportunity throughout the time Mrs [name redacted] was in hospital for this to be carried out.”
Later report
“if, from the falls risk assessment, there were concerns as to Mrs [name redacted] mobilising in and out bed and/or in and out of her chair and her stability then these would have been highlighted in the nursing notes/care plan and discussed at any handover”
Responses
2014-0064-Response-by-Stockport-NHS-Foundation-Trust.pdf ↗· Stepping Hill Hospital
Stated action
“We have instigated an escalation process whereby, if any equipment cannot be located within the mmediate ward environment, staff must contact the senior nurses on 'professional cover' for the Business 3roups by bleep in the first instance to assist in locating the equipment. Should the bleep-holder be unable '0 resolve the problem, this is to be escalated to the hospital site manager who will either locate the squipment or assist in the re-assessment of those currently in use across the hospital”