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recurance

Gladys Smith

17 Nov 2014 · Coroner Melanie Williamson · West Yorkshire (East)

The coroner's concerns

  1. 1. inadequate turning and repositioning of residents

    “a) Advice and instruction given to Care Home staff as to the turning and repositioning of Mrs [name redacted] was not followed and repositioning charts were not”
  2. 2. failure to body map bruises promptly

    “staff should ensure that all bruises sustained by residents are carefully body mapped at the first available opportunity”
  3. 3. delayed medical response to bruises

    “appropriate medical advice is sought at the first available opportunity upon noticing a bruise to a resident following an apparent impact injury”
  4. 4. inadequate falls risk management

    “falls assessments should be regularly undertaken in respect of all residents and regular consideration should be given as to the appropriate location of residents' rooms within the Care Home”
  5. 5. lack of weight monitoring

    “regular monitoring and appropriate recording of residents' weights”
  6. 6. absence of nutrition monitoring

    “nutrition charts are completed in respect of any resident whose weight falls significantly”

Responses

No published response was found on judiciary.uk.

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Source: Prevention of Future Deaths reports and responses published by the Courts and Tribunals Judiciary at judiciary.uk. Crown copyright, used under the Open Government Licence v3.0. Data updated 26 Oct 2026.

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Gladys Smith · Recurance