Jeanne Summers

1. 1. lack of mobility assessment before discharge

   “The assessment review of Mrs [name redacted]' ability prior to her discharge on the 6th July 2013. There is no clear indication that an assessment had been undertaken prior to Mrs [name redacted]' discharge on the 6th July 2013. Her condition was such that she required further readmission on the 7th July 2013.”

2. 2. incomplete physiotherapy documentation

   “During the further readmission on the 7th July 2013 Mrs [name redacted] was reviewed on a number of occasions by a physiotherapist. At the inquest Clinical Lead Physiotherapist, provided evidence and indicated that the physiotherapy written records did not provide a full record of all relevant details. These notes are reviewed by nursing staff in order to ensure the patient's safe mobilisation and the preparation of appropriate care plans. I would ask you to consider that additional training and/or”

3. 3. inappropriate footwear during mobilisation

   “From the evidence presented at the inquest it appears that at the time when Mrs [name redacted] was mobilising in the early hours of the 14th July 2013 she was wearing her own”

4. 4. lack of staff training on safe transfer and footwear

   “I would request you to consider training and guidance to nursing staff to ensure that, firstly, patients are wearing appropriate footwear prior to mobilisation and, secondly, to provide training guidance to staff of safe systems of transfer to ensure that patients are not left whilst in the process of transfer.”

5. 5. investigator lacks proper training

   “Matron gave evidence in respect of an investigation which she undertook in respect of the circumstances surrounding Mrs [name redacted]' fall. Matron indicated in her evidence that she had not received full training with regard to undertaking an investigation and preparing an investigative report.”

No published response was found on judiciary.uk.