Beryl Farmer
24 Nov 2016 · Coroner Zafar Siddique · Black Country
The coroner's concerns
1. falling risk
“Evidence emerged during the inquest that Mrs [name redacted] had a risk of a falling (moderate to high risk). There was no evidence that a falls risk assessment had been completed.”
2. unmonitored bay
“Given the risks of falls, there was no clear justification for moving her from a monitored bay to an unmonitored bay.”
3. neurological observations
“After the fall, only one set of neurological observations were performed before her discharge.”
4. CT Head scan
“In addition no CT Head scan was performed despite evidence of significant bruising to her face and head.”
Responses
2016-0420-Response-by-Sandwell-and-West-Birmingham-Hospitals-NHS-Trust.pdf ↗· Sandwell and West Birmingham Hospitals NHS Trust
Stated action · end of 2017
“We are going to amend our inpatient falls policy. This will help us to ensure that post incident monitoring is undertaken. It will also more clearly link our standards in ED and on the wards. It is unacceptable that in this situation the requested monitoring was discontinued. Our use of Vital Pac and the upcoming installation of our new electronic patient record by Christmas 2017 will provide decision support and alerts to reinforce our standards. These changes will be complete by the end of March”