Roger Southwick
16 May 2023 · Coroner Christopher Briggs · Manchester South
The coroner's concerns
1. inaccurate falls risk assessment
“There was a failure to complete the Falls Risk Assessment accurately”
2. failure to reassess fall risk after family concerns
“There was a failure to reassess the risk of falls when staff were informed by members of the deceased's family of his significantly compromised mobility and unsteadiness on his feet”
3. investigation report omission of prior concerns
“The Investigation Report prepared by the Trust failed to identify and therefore did not address issues 1 and 2 above”
Responses
2023-0158-Response-from-Tameside-and-Glossop-Integrated-Care-NHS-Foundation-Trust-.pdf ↗· Tameside and Glossop Integrated Care NHS Foundation Trust
Stated action
“The Trust have reviewed the Falls prevention policy and have identified further improvement to the policy which will now include the assessment of the patient to include changes from their 'baseline' mobility, this will facilitate a holistic patient and relative/carer approach to assessing mobility and any acute changes.”