Dorothy Macdonald
17 Dec 2025 · Coroner David Lewis · Liverpool and Wirral
The coroner's concerns
1. falls risk in frail elderly residents
“The Home Manager reported that the Deceased did not really know why she had come to the home and had a very poor short-term memory”
2. underestimated falls risk assessment
“staff assessed and documented her risk of falling as being at 'low' likelihood - a score of 2/5 on the likelihood scale”
3. ineffective falls team referral
“the Home Manager lacked confidence in the responsiveness or value of the service”