Marion Jones

“No pre-admission assessment for bed rails was recorded by the staff member responsible from Riverside, and this does not appear to have taken place. This is in circumstances where bed rails were already in place at Willow Wood and where there were obvious and recorded difficulties with regard to movement in and about bed, in addition to physical activity more generally. Given the circumstances, a pre-admission assessment for bed rails should have taken place and / or been recorded. The inquest heard that family members raised their concerns on admission of [the deceased] to Riverside when they saw there were no bed rails. They were assured that an assessment would take place. This did not happen: it should have done. The manager of the care home agreed that in all the circumstances, including the concerns of the family, such an assessment should have taken place. A registered general nurse involved in care for [the deceased], and who found her after she had fallen, gave evidence that an assessment for bed rails should have taken place 48-72 hours after admission. The manager of the care home gave evidence that such an assessment should take place as promptly as possible, and that 48-72 hours did not meet this requirement. The nurse did not appear to appreciate the time within which such an assessment should be conducted. Another registered general nurse involved in the care of [the deceased] gave evidence that she was not sure in what period of time an assessment for bed rails should take place. Therefore, nursing staff responsible for the care of [the deceased] did not know what the appropriate approach was to assessment for bed rails. The awareness of nursing staff at Riverside with regard to assessment for and / or the requirement for bed rails was not apparent The inquest heard that there have been previous incidents where bed rails have not been in place.”

“The care was to be palliative within the community. After being cared for by her family, she went into respite care at Willow Woods hospice and from there to Riverside care home. [the deceased] was unstable in her movement and required the assistance of one or two carers for most physical activities, including getting in and out of bed. At Willow Wood, [the deceased]'s bed had been fitted with bed rails. Prior to being admitted to Riverside, a pre-admission assessment was conducted by staff from Riverside. Although the relevant pre-admission form contains a section for assessment of safety equipment such as bed rails, no such assessment is recorded. Bed rails were”

“The inquest heard that family members raised their concerns on admission of [the deceased] to Riverside when they saw there were no bed rails. They were assured that an assessment would take place. This did not happen: it should have done. The manager of the care home agreed that in all the circumstances, including the concerns of the family, such an assessment should have taken place. A registered general nurse involved in care for [the deceased], and who found her after she had fallen, gave evidence that an assessment for bed rails should have taken place 48-72 hours after admission. The manager of the care home gave evidence that such an assessment should take place as promptly as possible, and that 48-72 hours did not meet this requirement. The nurse did not appear to appreciate the time within which such an assessment should be conducted. Another registered general nurse involved in the care of [the deceased] gave evidence that she was not sure in what period of time an assessment for bed rails should take place. Therefore, nursing staff responsible for the care of [the deceased] did not know what the appropriate approach was to assessment for bed rails. The awareness of nursing staff at Riverside with regard to assessment for and / or the requirement for bed rails was not apparent”