Valerie Hill (1)
13 Jun 2025 · Coroner Graeme Hughes · South Wales Central
The coroner's concerns
1. falls in care/nursing homes
“The identification of, and reduction of falls risks was a central feature of the evidence in the inquest. WAST, in particular had highlighted that falls in care/nursing homes have contributed significantly to the volume of activity in the community, having a domino effect/impact on delayed hospital handovers.”
2. lack of staff training on falls risk identification and documentation
“The material provided at, and post Inquest is absent in evidencing that staff at Ty Bargoed receive any specific, relevant, or effective training in respect of the identification & documenting of falls risks to residents, and the mitigation that can be put in place to reduce those risks. In particular, how the assessments ought to be approached and completed.”
3. focus on post-fall management rather than risk assessment
“the material filed with me focuses upon how to move a fallen person/their management post fall, not the identification /assessment/documentation of risk in order to prevent/mitigate the happening of such events.”
4. risk assessment forms not completed or counter-signed by Registered Healthcare Professional
“The exhibits to your statement at KL 1 page 58 appear to suggest that the risk assessment forms ought to be completed/counter-signed by a Registered Healthcare Professional. I received no evidence that such a practice was/is in operation at Ty Bargoed”
5. absence of Falls Prevention Strategy or Policy
“Your Exhibit KL1 at page 27 references regard being had to Falls Prevention Strategy or Policy - I have received no evidence that MTCBC have such available and in place to inform Care Home's and their staff in preparation for the completion of a resident's falls risk assessment”
6. unclear response to falls notifications by Health and Safety Unit
“Whilst I am reassured to an extent in relation to the management and retention of incident & risk assessment documentation created in Ty Bargoed moving forwards, I am unclear as to what action, if any, MTCBC's Health and Safety Unit take upon receipt of falls notifications (as described in [REDACTED]'s evidence) and what, if any, analysis/assessment/communication is undertaken in respect of the same with a view to supplementing the ongoing falls risk assessment and collateral mitigating measures.”