Kenneth Goodwin
14 Oct 2022 · Coroner Lauren Costello · Manchester South
The coroner's concerns
1. lack of written confirmation of handover for fall risk
“The Inquest heard that the transfer process between wards for patients at risk of falls does not require a specific written confirmation that a handover in relation to that risk has taken place”
2. delayed falls risk assessment
“The falls risk assessment on the new ward was not completed for just over 4.5 hours”
3. inconsistent visual fall risk indicators
“The Inquest heard that the use of signs on beds to visually identify falls risk to the staff is not consistently used”
Responses
2022-0318-Response-from-Stockport-NHS-Foundation-Trust-.pdf ↗· Stockport NHS Foundation Trust
Stated action · 15 November 2022
“The Trust's formal patient handover document was re-launched across the Trust on 15 November 2022, via the Trust's 'Risky Business' weekly bulletin and also via targeted e-mails from the · divisions governance teams.”
Stated action · 15 November 2022
“The requirement for the use of the maple leaf sign, identifying patients at risk of falls, was re launched across the Trust on 15 November 2022, via the Trust's 'Risky Business' weekly bulletin and also via targeted e-mails from the divisions governance teams.”