Terence James
17 Dec 2019 · Coroner Sonia Hayes · Kent (Central and South East)
The coroner's concerns
1. failure to inform GP of fall
“The GP was due to attend Mr [name redacted] on 17th April and was not informed of his fall prior to his attendance”
2. lack of fall history handover
“The history of the fall on 17th April was not handed over to care staff who had returned from leave on 20th April”
3. lack of escalation of pain concerns
“A chiropodist raised concerns on 18th April that Mr [name redacted] was in pain and this was not escalated for further medical advice”
4. delayed escalation of fall
“Mr [name redacted] sustained a further unwitnessed fall at approximately 10:25 on 20th April. This fall was not escalated for further medical advice until after a change of shift at 19:00 when his deterioration was immediately noted and escalated”