Hazel Wiltshire
1 Sept 2021 · Coroner Jonathan Landau · South London
The coroner's concerns
1. lack of monitoring of response times
“The matron who gave evidence was not aware of obtaining data on response times from the call bell system and had not introduced any other system to monitor response times”
2. inadequate staffing
“Staffing levels were inadequate due to higher dependency of patients with Covid”
3. absence of fall risk assessments
“Although Mrs [name redacted] was at risk of falls, no risk assessments were completed on any of the three wards in which she stayed”