Barbara Humphreys
23 Jul 2019 · Coroner Ian Boyes · South Wales Central
The coroner's concerns
1. use of mattresses not designed for particular beds
“The evidence in the case revealed a number of issues relevant to the use of bed rails and training of staff”
2. inadequate training on bed rails
“The second issue is also directed to Crosfield house Ltd and Care Inn limited and requires adequate training to be provided to all employees in the homes operated by your respective companies”
3. lack of risk assessment for bed rails
“The third issue is also directed to Crosfield house Ltd and Care Inn limited. The staff and care homes in general under your control should complete a full and frank risk assessment in relation to any and all issues with regards to bed rails”
4. absence of bed rail policy
“The fourth issue is directed to Crosfield house Ltd and Care Inn limited. The company should produce and implement a full bed rail policy which is either group wide or relevant specifically to Crosfield house Ltd”
5. delayed care plan completion
“The fifth issue is directed to Crosfield house Ltd and Care Inn limited which is there was evidence that the completion of care plans and best interests assessments was required to be fitted round other duties”
6. lack of family notification of incidents
“The sixth issue is directed to care Inspectorate Wales and National Health Service Wales. They shall consider and if so appropriate, draft and implement a policy which requires a care home or care provider to inform the family and next of kin of events in which are medically trained professional has attended to or seen the patient particularly in cases where there is no or varying capacity”