Robert Taylor
22 Oct 2024 · Coroner Louise Hunt · Birmingham and Solihull
A similar concern from this report was raised again 1 time later. See the linked reports.
The coroner's concerns
1. lack of enhanced nursing observations
“lack of enhanced nursing observations”
2. quality of post death investigations
“quality of post death investigations being undertaken by the Trust”
Linked reports
Identical hazardConfidence 0.90 · high
This report
“The central issue in this case relating to the fall on 11/06/24 was the lack of enhanced nursing observations.”
Later report
“Some, potentially all, of these falls occurred when Mr [name redacted] was not receiving the appropriate level of observation in accordance with his falls risk assessment and care plan.”
Responses
2024-0567-Response-from-University-Hospitals-Birmingham-NHS.pdf ↗· University Hospitals Birmingham NHS Foundation Trust
Stated action
“The Enhanced Care policy has been re-embedded into the ward and risks are discussed in the ward huddle following shift handovers.”
Stated action
“Acuity was noted to be a contributing factor within this case. There is currently a SNCT (Safer Nursing Care Tool) to review of acuity levels as part of the wider Trust review of acuity and dependency.”
Stated action
“The nurse in charge currently identifies and discusses patients at risk of falls, as well as those requiring enhanced observations, with the Matron, prior to the 0800- touchpoint meeting.”
Stated action · January 2025
“We have recognised that the current layout of ward 19 can be challenging when nursing patients who are at risk of falls because of having only two 6 bedded bays and 13 side rooms positioned in a T shape within the ward.”
Stated action · December 2024
“Following the death of Mr [name redacted] the department is currently delivering falls training, which is provided by the Falls team and has been attended by qualified nurses and health care support workers. To date 42.5% of ward staff have completed training with a further 40% of staff booked on to the training for December 2024.”
Stated action
“The witnesses and the investigation report did not address the central issue relating to the fall and this raises a concern about the quality of post death investigations being undertaken by the Trust.”