Margaret Tuck
26 Jul 2016 · Coroner ME Hassell · London Inner (North)
The coroner's concerns
1. falls risk assessment without appropriate prevention plan
“1. Although a falls risk assessment was conducted upon [the deceased]'s admission to hospital, when it demonstrated an increased risk of falling no falls prevention care plan was drafted. And, whilst most of the preventative measures that would have been detailed on such a care plan were implemented in any event, Mrs [name redacted] was described on the risk assessment as having no walking aids. In fact, she had a zimmer frame, and it was while reaching for this zimmer frame that she fell on the acute”
Responses
2016-0273-Response-by-Barths-Health-NHS-Trust.pdf ↗· Royal London Hospital
Stated action
“The Hospital has undertaken a major piece of work to ensure vulnerable patients are identified and cared for, ensuring their risk of falling is minimised. A falls working group meets monthly, with each clinical area having to present their incidence of falls and work in progress around reduction of these incidents. On the AAU (representative of most clinical areas) all patients are assessed using the Trust falls assessment paperwork (which has been newly amalgamated into a nursing documentation”