Doris Urch
11 Aug 2023 · Coroner Harry Lambert · Inner North London
The coroner's concerns
1. risk assessment process
“The Question and Answer tickbox form for Risk Assessment seemed to me to leave much to be desired”
2. lack of actionable recommendations
“The Risk Assessment did not make no recommendations or suggestions as to what to do about the risks identified”
3. staff unfamiliarity with risk assessment
“Staff seemed unfamiliar with the risk assessment/care plan”
4. outdated care plan after fall
“The care plan/risk assessment was not updated in light of a fall in November/December 2022”
5. loss of historical care plans
“The system does not preserve old care plans in their contemporaneous format”