Marion Nickson
21 Jul 2023 · Coroner Alison Mutch · Manchester South
The coroner's concerns
1. unobserved falls in high‑risk patients
“to deal with the risk of falls in patients deemed to be high risk the concept of observable bay nursing had been introduced at both Trusts”
2. avoidable patient falls leading to death
“preventing in patient falls to reduce avoidable deaths was recognised as being important and that across the NHS bays of this nature were seen as a way to reduce the risk”
3. continued avoidable falls and deaths
“if observable bays could not function as intended then across the NHS there would continue to be avoidable falls and consequential deaths”
4. resourcing limitations compromising patient safety
“If bay nursing could not effectively delivered due to resourcing then other options to keep patients safe needed to be explored by Acute Trusts”