Patricia Heslop

“The fall was unwitnessed and went unreported.”

“There appears to have been a change in [the deceased]'s presentation and a number of factors, which were not collated in the days preceding her hospital admission including: e the unusual and regular use of a wheelchair; e the rocking manoeuvre by two members of staff to get [the deceased] from her chair; e the fact that two members of staff would walk with [the deceased].”

“It is important that family members have confidence in the provision of care to a loved one and have regular information provided to them.”

“A number of terms were used about [the deceased]'s developing condition:”

“There was evidence that care plans had not been updated, various documents not reviewed or read by others, as well as that records were incomplete or inaccurate. For example, the impression was given of [the deceased] being in a chair for 13 continuous hours and in bed for 17 hours with concerns about her fluid/nutritional intake as well as her personal needs.”

“Despite [the deceased] having fallen sometime in the early part of November no attempts were made at that time to take statements from various witnesses about the fall while events were fresh in their memories.”