Roger Tombs
13 Feb 2017 · Coroner Emma Brown · Birmingham and Solihull
This report repeats 1 earlier warning. See the linked reports.
The coroner's concerns
1. sensor mats placed on crash mats
“The evidence was that fall sensor mats had been placed either side of Mr. [name redacted]' bed on top of crash mats. At the time of his fall on the 3% May 2016 the sensor mats did not sound an alert”
2. sensor mats placed on soft surface
“The instructions for use of the sensor mats state they should be placed ona hard floor”
3. crash mats reducing sensor effectiveness
“The investigating police officer from the public protection unit gave evidence that she was concerned that the crash mats below the sensor mats would reduce the effectiveness of the sensor mats and this could possibly be the reason the mat didn't sound”
4. reduced sensor effectiveness
“[tis my opinion that there is a risk that the effectiveness of the sensor mats is being reduced by placing them on crash mats and if this is the case they may not sound when vulnerable residents are mobilising exposing them to a risk of falls, injury and potentially death”
Linked reports
Closely relatedConfidence 0.80 · moderate
Earlier report
“Are all the staff members now clear as to the Rules relating to the positioning of the profile beds? Is there a rule about the need for crash mats and sensor mats on both sides of the bed?”
This report
“The evidence was that fall sensor mats had been placed either side of Mr. [name redacted]' bed on top of crash mats. At the time of his fall on the 3% May 2016 the sensor mats did not sound an alert”
Responses
2017-0027-Response-by-Sunrise-Senior-Living.pdf ↗· Sunrise Senior Living
Roger-Tombs-Response.pdf ↗· Care Quality Commission
Stated action · 4 April 2017
“I have reviewed practice within the team in relation to the issue of advice and training of this nature and find that it is both consistent and accurate. Furthermore, to support the dissemination of this across the care home sector, a guidance document has been developed outlining good practice in the use of sensor mats and is enclosed for your reference. This was sent on 4 April 2017 to [name redacted] - Acting Strategic Commissioner for Older People, Solihull Metropolitan Borough Council (SMBC)”