Anthony Wood
3 Jun 2025 · Coroner John Taylor · South London
The coroner's concerns
1. patient fall
“the patient was identified as at high risk of a fall”
2. patient frailty
“he was deemed to be severely frail (and hence at corresponding risk, if a fall were to occur)”
3. absence of crash mats
“there were no crash mats at the side of his bed”
4. patient aggression
“it was known that the patient had a propensity to push staff when being changed”
5. unsecured bed-rail
“the bed-rail was not up when the patient was attended by a HCA acting alone”
6. insufficient staffing
“the patient should have had the assistance of two members of staff, and not just one, when being prepared to be washed and changed”
Responses
No published response was found on judiciary.uk.