Recurance · prevention of future deaths reports
Pre-inquest brief
Missed falls risk assessment
The earlier warning
Laura Hill · 17 Feb 2014 · Joanne Kearsley, Manchester (South)
“Despite training being in existence in relation to the carrying out of Falls Risk Assessments there was a missed opportunity throughout the time Mrs [name redacted] was in hospital for this to be carried out.”
What was promised
Stated action 1 · response to Laura Hill (17 Feb 2014) · stated timescale: none stated
“We have instigated an escalation process whereby, if any equipment cannot be located within the mmediate ward environment, staff must contact the senior nurses on 'professional cover' for the Business 3roups by bleep in the first instance to assist in locating the equipment. Should the bleep-holder be unable '0 resolve the problem, this is to be escalated to the hospital site manager who will either locate the squipment or assist in the re-assessment of those currently in use across the hospital”
judiciary.uk/…/2014-0064-Response-by-Stockport-NHS-Foundation-T…
What recurred
- 26 Aug 2016 · Maureen Flynn · Andrew Bridgman · Identical hazard · confidence 0.90 (high)
The clearest link, quoted from both reports:
Earlier · Laura Hill · 17 Feb 2014
“Despite training being in existence in relation to the carrying out of Falls Risk Assessments there was a missed opportunity throughout the time Mrs [name redacted] was in hospital for this to be carried out.”
Later · Maureen Flynn · 26 Aug 2016
“if, from the falls risk assessment, there were concerns as to Mrs [name redacted] mobilising in and out bed and/or in and out of her chair and her stability then these would have been highlighted in the nursing notes/care plan and discussed at any handover”
What happened next
No web check of the stated actions has been published for this chain.