Margaret Austin
27 Nov 2023 · Coroner Janine Richards · County Durham and Darlington
The coroner's concerns
1. high risk of falls
“The deceased was known to be at high risk of falls and the documentation in relation to how to manage that known high risk of falls was not comprehensive and contained significant discrepencies as to what should, in fact, be in place, and contained no rationale for why further measures which may have been considered appropriate were not in situ or considered appropriate or necessary.There was no evidence that the risk management plan was reviewed as the deceased's risks changed nor in the after”