Ronald Perry
14 Nov 2025 · Coroner Alison Mutch · Manchester South
This report repeats 1 earlier warning. See the linked reports.
The coroner's concerns
1. incomplete documentation of care and risk
“During the course of the inquest it was difficult to be clear at times as to what care had been delivered or what steps had been taken because the documentation relating to care and risk was poor.”
2. incomplete falls risk assessment documentation
“The falls risk assessment documentation was incomplete and did not appear to have been updated after falls had occurred.”
3. lack of understanding and adherence to falls policy for anticoagulated residents
“The falls policy regarding the need to seek medical advice where a resident on anticoagulation had a fall that had been unwitnessed did not seem to be widely understood by staff or adhered to on all occasions.”
Linked reports
Closely relatedConfidence 0.90 · high
Earlier report
“there was no clear system or expectation regarding the quality of checks on a resident who exhibited signs of being unwell.”
This report
“During the course of the inquest it was difficult to be clear at times as to what care had been delivered or what steps had been taken because the documentation relating to care and risk was poor.”