Doris Smith
27 Feb 2023 · Coroner Sonia Hayes · Essex
The coroner's concerns
1. delayed completion of falls risk assessment
“delayed the completion of a falls risk assessment”
2. inaccurate falls risk assessment
“completed the falls risk assessment with inaccurate information to assess [the deceased]'s risk and updates were also inaccurate”
3. failure to follow physiotherapist advice
“did not follow the advice of the physiotherapist that would have required [the deceased] to mobilise only with assistance of staff and whether her level of observations should have been changed”
4. incomplete neurological observations
“Neurological observations following a sustained head injury were not completed as required”
5. falls not leading to observation reassessment
“[the deceased] had falls on the ward and her level of observations was not reconsidered in light of advice from the physiotherapist after each fall”
6. confusing observation policy
“The Trust Observation Policy is used in different therapeutic settings and is confusing as to the Levels of Observation required and the focus is on risk for mental health rather then physical healthcare issues that may arise”
Responses
2023-0074-Response-from-Essex-Partnership-University-.pdf ↗· Essex Partnership NHS Foundation Trust
Stated action · within 24 hours of admission
“Within 24 hours of admission, the Guide To Action falls assessment is completed and staff are expected to update the falls risk assessment whenever there has been a change in the patient's clinical condition.”
Stated action
“The falls risk assessment is included in the local induction of all clinical ward staff band 2 to band 7 and for the induction of temporary workers. Knowledge and understanding is also reviewed in the probation period of substantive staff members through discussions, which usually concludes after the first six months of employment.”
Stated action
“The SOP for falls management in the inpatient setting will guide staff through the process required when there is a concern about the risk of a fall, how to prevent a fall within the inpatient setting including specific information on expert advice from occupational therapy and physiotherapy teams, and the steps required to safeguard a patient's safety when a patient does have a fall.”
Stated action
“Posters are displayed in patient bedrooms to clearly inform the patient and supporting staff of the mobility assistance they require, and includes details of aids they may require for the hearing and visual needs.”
Stated action · January 2023
“Falls Champions Networks were re-launched in January 2023 as part of the Trust's Physical Health Care meeting. Each ward have an identified registered member of staff who attend the meeting and feedback learning, changes in policy and practice developments in their local team.”