Patricia Heaviside
10 Jul 2025 · Coroner Rebecca Sutton · County Durham and Darlington
This report repeats 1 earlier warning. See the linked reports.
The coroner's concerns
1. lack of falls prevention equipment
“Despite recommendations for falls prevention equipment being made by the Community Falls Service in August 2023, no falls prevention equipment was put in place by the time of the Deceased's fall in October 2024”
2. lack of falls prevention equipment
“Despite the social worker expressing concern about the lack of falls prevention equipment on 27 September 2024, no falls equipment was put in place prior to the Deceased's fall on 4 October 2024”
3. lack of information sharing
“Information about the Community Falls Service recommendations was not passed on to the family, or to social services”
4. reluctance to fund equipment
“On 5 August 2024 (following a fall, but before the more significant fall on 4 October 2024), the Deceased's family were told by the Deputy Manager of Howlish Hall that the owner of Howlish Hall”
5. reluctance to fund equipment
“I received evidence that, subsequent to the Deceased's death, there had been a reluctance on the part of [REDACTED] (who was believed to be the owner of Howlish Hall Care Home) to provide adequate resources for falls prevention equipment”
6. lack of DoLS assessment
“Despite it being recognised that the Deceased lacked mental capacity to make decisions about where she lived and was unable to keep herself safe, it appears that the home did not make any application for a DoLS assessment for the Deceased”
Linked reports
Identical hazardConfidence 0.90 · high
Earlier report
“The care home may not have some of the equipment that they require for patients such as Mrs [name redacted] e.g. a bed sensor mat.”
This report
“Despite the social worker expressing concern about the lack of falls prevention equipment on 27 September 2024, no falls equipment was put in place prior to the Deceased's fall on 4 October 2024.”