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Sheila Ross

19 Mar 2018 · Coroner Derek Winter · Sunderland
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The coroner's concerns

  1. 1. outdated falls risk assessment tool

    “The falls risk assessment tool used by the Care Home staff appeared to be outdated, and the subsequent level of falls risk recorded by staff was not in keeping with the score generated by the assessment tool.”

  2. 2. limited buzzer system activation

    “The Care Home buzzer system only allowed one alert mechanism - personal buzzer or sensor mat - to be active at any one time, unless a resident could access the wall buzzer.”

  3. 3. poor communication with family

    “There was poor communication from the Care Home with [the deceased]'s family members, which led them to lose confidence in the standard of care [the deceased] was receiving.”

Responses

No published response was found on judiciary.uk.

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Source: Prevention of Future Deaths reports and responses published by the Courts and Tribunals Judiciary at judiciary.uk. Crown copyright, used under the Open Government Licence v3.0. Data updated 26 Oct 2026.

A link shows that a similar concern was raised again, not why. It is not a finding about any organisation or person. Methodology and responsible use · Report an error