Edith Alden
16 Apr 2024 · Coroner Jacqueline Lake · Norfolk
The coroner's concerns
1. inconsistent and unclear care plans and risk assessments
“Care Plans and Risk Assessments were not consistent and clear as to what steps were required to mitigate the risks of Mrs [name redacted] falling”
2. staff unclear about required mitigation steps
“Staff were unclear in evidence as to what was required in respect of Mrs [name redacted] to mitigate the risks of her falling”
3. high‑risk residents left unattended in communal areas
“Residents deemed as at very high risk of falls were, and still are, allowed in communal areas with no carer present”
4. insufficient staffing levels
“Staffing levels may be insufficient for the number of residents. Evidence was heard that "staff can't be everywhere at once”
5. lack of alert system for residents leaving rooms
“Residents deemed as at very high risk of falls were, and still are, in their bedrooms with a call bell and no other means to alert staff if they get out of bed and mobilise”
6. unsupported inspection claim of adequate staffing
“The Inspection Report dated 6 October 2022, carried out following Mrs [name redacted] death, found "There were enough staff on duty to meet people's needs and people told us they never had to wait long for assistance.”