Elizabeth Robinson
12 Mar 2021 · Coroner Caroline Saunders · Gwent
This report repeats 1 earlier warning. See the linked reports.
The coroner's concerns
1. lack of awareness of internal investigation findings
“neither of the nursing staff who gave evidence had seen the findings of the internal investigation some 1 years and 4 months since Mrs [name redacted] death”
2. inadequate falls risk assessment and supervision
“Mrs [name redacted] was at high risk of falls and were monitoring her as closely as possible with the staffing complement available.”
Linked reports
Closely relatedConfidence 0.80 · moderate
Earlier report
“Staffing levels of Tissue Viability Nurses within the Aneurin Bevan Health Board are low and to the extent that at times this service cannot be provided according to need;”
This report
“Mrs [name redacted] confirmed that staffing levels were not considered during the investigation and it was further confirmed that these apparently low staffing levels still exist.”
Responses
2021-0072-Response-from-Aneurin-Bevan-University-Health-Board-Redacted.pdf ↗· Aneurin Bevan University Health Board
Stated action · June
“a full acuity audit will take place during the month of June. This will provide essential intelligence to support a triangulated re-calculation in August 2021, to determine appropriate nurse staffing levels on all Community Wards in YYF.”