Robert Jones

“There was no evidence of communication to ensure that all staff including the different GPs visiting, were aware of the total number of falls the patient has sustained.”

“An out of date post falls checklist was used which does not include specific details of the frequency in duration of neurological observations as recommended by NICE, where head injury has occurred and can or cannot be ruled out and the patient did not always have his neurological observations recorded as per the minimum recommended.”

“They were not always recorded correctly on the observation charts.”