Sylvia Savage

“There was I heard no clear definition of when to report falls externally & internally - this to me is perhaps the reason why the fall Mrs [name redacted] suffered on 1/2/23 was not recorded internally, all be it CQC were notified on this occasion. The fall on 18/3/23 was not reported to CQC and whilst I understand staff at the care home did not know the outcome of Mrs [name redacted] treatment in hospital - she left the home by ambulance and did not return. This seems an occurrence worthy of reporting- it strik”

“The evidence is clear that the provided sensor mat was not an efficient way of monitoring Mrs [name redacted] when she attempted to mobilise. It was well known in the home that Mrs [name redacted] defeated it's purpose by moving or unplugging it. There seems to have been a lack of thought as to an alternative measure. The wall mounted sensor, for example was seen by the expert as a reasonable measure - the home manager said he could consider them and the regional manager indicated they were used in the company,”

“Mrs [name redacted] fall in February 2023 was it appears reported to her GP by her daughter and that led to a nurse attending the home to examine her. Staff at the home do not appear to have done so themselves. It is of concern that after a fall the staff within the home should have a mechanism to ensure medical advice is obtained in a timely fashion and that it is documented clearly and not be reliant on family members summoning help for residents themselves when they have become aware of an incident.”

“The absence of records has hindered my investigation into Mrs [name redacted] death. The expert in her evidence made it clear - good recording keeping allows staff to monitor Changes in condition, allows new staff or those returning from time off to reacquaint themselves with residents condition and allows clinicians to make diagnosis - without access to good records I can see a clear risk to the care of residents. It is also surprising to me the complete reliance on paper records which have in Mrs [name redacted]”

“The evidence I have heard is after Mrs [name redacted] fall on 1/2/23 and when it became clear the sensor mat was not working as intended - this should have prompted staff to return to the care plans and re-evaluate them - it did not. Indeed one care home witness stated as Mrs [name redacted] had not had 3 falls in 3 months no change to her plan was needed. Given the second fall Mrs [name redacted] had some weeks later gave her injuries that led to her death this approach appears flawed. Whilst I acknowledge work is”