Maureen Flynn
26 Aug 2016 · Coroner Andrew Bridgman · Manchester (South)
This report repeats 1 earlier warning. See the linked reports.
The coroner's concerns
1. uncompleted falls risk assessment leading to missed safety concerns
“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”
2. staff unaware of incomplete falls risk assessment
“those caring for a patient were ignorant of the fact that Mrs [name redacted] falls risk assessment had not been completed”
3. HCA unaware of incomplete falls risk assessment
“It is clear that the HCA was unaware”
4. absence of alert system for incomplete assessments
“t would seem eminently sensible to adopt a system whereby staff are alerted to the fact that a falls risk assessment has not been completed”
5. Patient Safety Investigation missed incomplete assessment
“am further concerned that the Patient Safety Investigation did not identify that fact that the falls risk assessment had not been completed”
Linked reports
Identical hazardConfidence 0.90 · high
Earlier 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.”
This 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
2016-0310-Response-by-Stockport-NHS-Trust.pdf ↗· Stepping Hill Hospital
Stated action · August 2016
“Please see attached the June ward newsletter for your information (page 2). In August 2016, | can confirm that the findings of the Coroner's Inquest was shared on Ward E2 and attention drawn to the need for fall risk assessments to be reviewed when a bed-bound patient starts to sit out in a chair. Please see attached the August ward newsletter for your information (page 2).”