Sheila Johnson
6 Sept 2023 · Coroner Paul Cooper · Lincolnshire
The coroner's concerns
1. inadequate falls prevention policy
“An inadequate generic falls prevention policy appeared to be in place”
2. unlocked doors to unoccupied rooms
“Doors to unoccupied rooms were unlocked when they should have been locked”
3. absence of night lights in common areas
“Night light in common places not on”
4. missing signage for bell ring
“No signage to bell ring in place”
5. inadequate nightly observations
“Indequate periodic nightly observations recorded at inquest.”