Howell Fisher

1. 1. falls while high risk

   “Within the space of a month the deceased had at least 5 falls whilst being deemed as high risk of falls. He was identified as requiring one to one nursing but there were many occasions when insufficient staff numbers meant that that could not be delivered.”

2. 2. lack of handover material and missed falls risk assessment

   “There was no "handover material' at the point of transfer between the two hospitals detailing that he was at high risk of falls and further more on readmission to the Princess of Wales Hospital on the 20" November no falls risk assessment was carried out - indeed, after each successive fall in the Princess of Wales Hospital no formal assessment appears to have been undertaken”

No published response was found on judiciary.uk.