Elsie Hayward

“4. Onthe 7" January 2015 medical staff were having to care for 50% more patients over what is generally considered to be safe staffed patient ratio. The evidence showed that the team was significantly overstretched and as a result were not able to oversee the care to this lady. Because of the pressures on the team it is likely that there were deficiencies in the care afforded to her which may have contributed to her repeated falls.”

“Despite clear guidance and directive the neuro observations on the deceased following her head injury where not undertaken in accordance with the Health Boards procedure and the N.I.C.E. national guidance.”

“There were extensive omissions in the note taking and a clear inconsistency between the "nursing notes" and "clinical notes" resulting in confusion and a breakdown of communication between the nursing staff and the medical team”