Eric Bird
10 Feb 2021 · Coroner Joanne Lees · Black Country
The coroner's concerns
1. lack of physiotherapy referral
“After Mr [name redacted] admission and initial falls risk assessment, there was a reference that Mr [name redacted] needed to be referred to the physio team but no evidence this was actually done”
2. failure to call emergency services after falls
“The inquest heard that Castlehill polices had not been followed after each fall whereby Mr [name redacted] had hit his head. Mr [name redacted] was taking apixaban which meant he was at a higher risk of bleeding. Evidence was heard that policy required 999 to be called. This was not done on 1/11/20 nor on 14/11/20”
3. incorrect emergency call made
“On 21/11/20 the nurse on duty called 111 instead of following policy to call 999”
4. ambulance access delay
“On arrival the ambulance was unable to gain access to the care home until 22.11 as there was no answer at the door”
5. lack of falls care plan updates
“There was no evidence that Mr [name redacted] falls risk assessment and falls care plan had been updated after every fall”
6. inadequate incident recording
“There were discrepancies in the recording of the falls on the monthly accidents and incidents form and no evidence that any consideration had been given to a pattern of falls which needed to be addressed to reduce Mr [name redacted] apparent increasing risks”