Sarah Hill
26 May 2025 · Coroner Margaret Taylor · Cumbria
The coroner's concerns
1. inadequate falls risk assessment and reporting
“There was a lack of evidence suggested appropriate falls risk assessments had been undertaken and a failure to report falls / collapses on the ward”
2. inadequate documentation of cot side use and call bell placement
“There was a lack of documentation about the use of cot sides and the placement of the call bell within Mrs [name redacted] reach”
3. inadequate observation frequency
“There was a lack of frequent recorded observations necessitated by Mrs [name redacted] deteriorating condition”
4. inadequate monitoring in side room
“Mrs [name redacted] was placed in a side room where she was not easily observed without consideration given for the need for additional monitoring which led to her being left alone for extended periods of time”
5. excessive patient to nurse ratio
“I was advised that the ward was understaffed and under pressure .I was told that despite this being appropriately escalated nurses were caring for 10 patients when the expected allocation would be 6 patients for each nurse on duty .No further help was provided to the ward following escalation . The evidence presented to me was that this was not an unusual situation on the ward”