Raymond Powell
29 Mar 2021 · Coroner James Bennett · Birmingham and Solihull
This report repeats 1 earlier warning. See the linked reports.
The coroner's concerns
1. lack of internal investigation into death
“The nursing home manager confirmed that Cole Valley Nursing Home had not conducted an internal investigation into the circumstances of [the deceased]'s death”
2. unrecorded preceding fall
“The nursing home manager confirmed that a preceding fall (most likely on 15 October) had not been recorded anywhere within [the deceased]'s file”
3. inaccurate falls risk assessment update
“The nursing home manager in her written report 5 to the Coroner stated that [the deceased]'s falls risk assessment had been updated.”
4. misleading observation log
“On 3 November staff were observing [the deceased] every 15 minutes however they only endorsed the 30 minute boxes on his observation log meaning it was misleading”
5. non compliance with court orders
“The nursing home failed to comply with repeated court orders to supply relevant evidence”
6. failure to learn lessons
“I am concerned that the nursing home has not sought to learn the lessons from the circumstances of [the deceased]'s death and as a consequence there is an ongoing risk to other residents”
Linked reports
Closely relatedConfidence 0.85 · high
Earlier report
“The current falls Risk Management and Risk Assessment documents (requested by the CQC and CCG) are undated and unsigned and continue to place reliance on the presence of a staff member to prevent falls”
This report
“The nursing home manager in her written report 5 to the Coroner stated that [the deceased]'s falls risk assessment had been updated. However, the evidence revealed in fact the falls risk assessment had been created on 30 September upon [the deceased]'s arrival, and had never been updated”