Pauline Brumfitt

“The policies and procedures in existence at the care home pertaining to falls risk assessment and prevention were not applied to [the deceased] (as stated above) as they should have been.”

“[the deceased] fell on 3 occasions and the opportunities to assess [the deceased]'s risks and take appropriate action to prevent further falls were not taken as they should have been.”

“The matter was (given in evidence) not reported to the regulatory bodies and again as given in evidence an investigation had not been commenced at the time of the inquest and staff supervision/discussion re falls prevention had only been commenced in Feb/March 2021, appropriate timely action could have helped (and could still help) to prevent future deaths in similar circumstances where dependent elderly residents are at risk of falling and suffering serious injury/death as a consequence.”