Absence of falls care plan

Each row is one judged link between an earlier and a later report. Open a row to read both quotes, found word for word in the originals. ?Every quote shown was checked by code to appear word for word in the original report.

• 2015 → 2023Iris Fordham7 years 11 months after David White · different coronerClosely relatedConfidence 0.90 · high

  Closely relatedConfidence 0.90 · high

  Both reports highlight shortcomings in managing patients identified as at risk of falls, specifically gaps between documented risk and actual protective actions.

  David White · 11 Nov 2015

  “(2) Nursing notes documented a risk of falls/mobilisation and action to be taken, but there was no supervision arrangement in place. One to one care had been in contemplation.”

  Check it in the source

  Iris Fordham · 5 Oct 2023

  “3. The consequence of (2) was that no falls care plan was completed.”

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  Stated action in the response to the earlier report

  “The safety briefing during nursing handover is now to include a verbal handover of the care plans for patients assessed as at risk of falls to alert incoming staff members as to the risk and care plan.”

  Earlier report in the app · Later report in the app

• 2023 → 2024Ian Hegarty1 year 1 month after Iris Fordham · different coronerClosely relatedConfidence 0.90 · high

  Closely relatedConfidence 0.90 · high

  Both reports concern failures to implement or follow a falls‑prevention care plan. The earlier report notes that no falls care plan was completed; the later report states that an existing falls‑risk reduction plan was not followed.

  Iris Fordham · 5 Oct 2023

  “The consequence of (2) was that no falls care plan was completed.”

  Check it in the source

  Ian Hegarty · 28 Oct 2024

  “That the plan of care put in place specifically to reduce the risk of falls for multiple patients was not followed.”

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  Earlier report in the app · Later report in the app