John William Wright
31 Oct 2013 · Coroner Gail Elliman · London Inner North
The coroner's concerns
1. fall without investigation
“There was no investigation of the cause or potential cause of the fall (whether there were any external factors involved - water on the floor, over-cleaning or any other high risk matter) so as to ensure that further falls could be prevented if necessary. Even if it transpired that the cause could not be determined, the fall should have been treated as a Serious Untoward Incident that warranted some kind of investigation. The North Middlesex University Hospital NHS Trust Serious Incident Policy”
2. inadequate staff training on fall protocols
“It was not at all clear from the evidence whether the training on falls policy and the protocols related to the recording of witnessed falls extended to the doctors as well as nurses and it is clear that, as a fall may be witnessed by any staff member at a hospital, the proper protocols should at least be known even if access to electronic means of recording an incident is limited for reasons of confidentiality.”
Responses
No published response was found on judiciary.uk.