Francis Langley
4 Sept 2017 · Coroner David Ridley · Wiltshire and Swindon
The coroner's concerns
1. safety bedrails not engaged
“the reason safety bedrails were not engaged is the fact that [the deceased] did not have a history of falls from bed”
2. risk assessment inconsistency
“the assessment that was carried out on 12 February a few days before the fall from bed on 17 February 2017. In response to the question as to whether or not [the deceased] was at risk from falls from bed the answer was”
3. inconsistent risk assessment approach
“The style is very different to the pital approach and in conjunction with this | have regard to a statement from ho was the Forest Ward Manager at the relevant time marked C.”