Julia Murphy

1. 1. incomplete misleading inaccurate referral forms to falls prevention team

   “[the deceased] had 21 falls, the final fall led to her death. The 3 referral forms sent to falls prevention were incomplete, misleading and/or inaccurate. An action plan in respect of preventing future deaths from falls/falls prevention/the learning following these events was not presented at Inquest nor did there appear to be a clear plan to address inter alia;”

2. 2. inaccurate or delayed reporting of falls

   “Accurate/timely reporting of falls/accurate timely, completion of referral forms to the falls prevention team”

3. 3. lack of escalation for high fall count

   “Escalation when such a significant number of falls were sustained by 1 frail, elderly person”

4. 4. unmet needs of resident with evolving dementia

   “Meeting the needs of the resident with evolving dementia, particularly in respect of mobility, supervision, falls prevention and risk assessment”

5. 5. lack of formal 1-1 supervision funding

   “Formally requesting 1-1 supervision funding when necessary/as appropriate on a case by case basis”

6. 6. absence of training and learning on falls prevention

   “Training/development/organisational learning following these events re falls prevention and accurate reporting/escalation”

No published response was found on judiciary.uk.