Ivy Mitchell
18 Jul 2017 · Coroner Alison Mutch · Manchester (South)
The coroner's concerns
1. inaccurate falls risk documentation
“The documentation relating to the falls risk was inaccurate. It did not refer to previous falls and did not reflect her mobility”
2. lack of understanding of risk assessments and post-fall processes
“There was a lack of understanding amongst the care home staff of risk assessments; reviews and the required process following a fall. This included documenting observations after a fall”
3. non-compliance with escalation processes after a fall
“Processes relating to escalation following a fall were not complied with”
4. lack of understanding of referral trigger to nutrition team
“There was a lack of understanding of the trigger for a referral to the community nutrition team”