“The record keeping in the home appeasers to be inaccurate and inconsistent (2) The falls…”

The coroner’s concerns

– (1) The record keeping in the home appeasers to be inaccurate and inconsistent (2) The falls policy of the home states that there are number of scenarios to consider before lifting a resident for the floor and states that the resident should not be moved until clinical assistance arrive. One such situation is if head, neck, back or hip injury is suspected. The incident log on advanced care cloud states there was ahead injury yet Mrs Dale was moved and no clinician saw her until she worsened and an ambulance was called. Inaccuracies in reporting can lead to missed opportunities to provide care and inaccurate time recording of incidents can lead to the accurate appraisal of the developing clinic picture being made more difficult which in turn would lead to a delay in medical assistance being sought. This could lead to resident safety being compromised and deaths occurring. (3) The senior care worker who came on shift later that day said she did not receive any hand over from the staff going off shift. This is a 2 concern as observations need to be carried out when someone has fallen and banged their head and a handover would detail such incidents and whether there are any concerns with residents.

An extract. Read the full report, including the circumstances of the death, on the Courts and Tribunals Judiciary website.

Source

judiciary.uk, Prevention of Future Deaths reports, 2026-0321

Added to Minute Book

8 Oct 2026

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Contains public sector information licensed under the Open Government Licence v3.0. Source: Courts and Tribunals Judiciary, judiciary.uk. Open Government Licence v3.0