Recurance · prevention of future deaths reports
Pre-inquest brief
Inadequate falls risk assessment update
The earlier warning
Jean Cutler · 8 Feb 2019 · James Bennett, Birmingham and Solihull
“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”
What was promised
Stated action 1 · response to Jean Cutler (8 Feb 2019) · stated timescale: 03rd April 2019
“New, comprehensive Falls Risk Assessments (FRAs) for all residents have been introduced and completed. The FRAs consider internal and external risk factors, provide a risk score which then generates a”
judiciary.uk/…/2019-0040-Response-by-Cole-Valley-Nursing-Home.p…
What recurred
- 29 Mar 2021 · Raymond Powell · James Bennett · Closely related · confidence 0.85 (high)
The clearest link, quoted from both reports:
Earlier · Jean Cutler · 8 Feb 2019
“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”
Later · Raymond Powell · 29 Mar 2021
“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”
What happened next
No web check of the stated actions has been published for this chain.