Kenneth Smith

After a purported re-assessment of the falls risk posed by the deceased on the 22 of October 2020 following his 14-day period of self-isolation in his room the evidence established that the deceased was to suffer 6 falls between the 22% and 29" of October 2020.

Two of these falls took place on the 22.4 of October 2020 — the same date of the reduction in the level of care being offered.

The evidence from the care home manager indicated that there was no date that had been given for a future review. It was also accepted that there was no action taken to consider a further falls risk assessment after any of the falls recorded in the Accident Record including no action taken on the 29" of October 2020 when the deceased suffered two falls, resulting in skin tears and a head injury.

Additionally, the evidence established that on release from hospital to the care home on the 8" of October 2020, the discharge clinicians had stopped the prescription of Trazadone to the deceased because it was too sedating. There was no evidence that the change in medication regime had been taken into account by carers adequately, or at all (as part of the falls risk assessment).

Care staff had only escalated concerns over the deceased's progressive agitation to a general practitioner on the 30" of October 2020. This had resulted in a referral to the Older Person’s Mental Health Team. There was no evidence as to why further advice from a mental health practitioner was not sought earlier, or as part of the risk assessment on the 22" of October 2020.

The nature and quality of the care received by the deceased between the 22" and 31% of October 2020 reveal the following concerns:

1. The decision to reduce the level of supervision was suboptimal, incorrect and flawed;

2. The failure to consider and specify a review date:

3. Alack of escalation process in the event of problems or issues with the reduced care plan that might prompt an urgent review;

4. The events of the 31% of October 2020 had not triggered any serious or untoward incident review by the care home, the CCG, or local authority;