John Long

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1. The bed rails affixed to patients beds allow a patient to fall easily from the patient's bed and the make and manufacture of bed rails should be reviewed to ensure they are fit for purpose and act to ensure the patient is secure in their bed and also prevent a patient accidentally from their bed. A review is required into the use of 1:1 (one to one) care in hospital wards and in particular a review into the definition of what 1:1 (one to one) care actually means: In addition a review on how it is administered on the ward and what rules there are for those nurses and Carers to comply with when carrying out such care for a patient: Furthermore there needs to be very clear rules about how Carer or nurse carrying out such care ensures they have sufficient breaks from providing such care and how are relieved from their duties in such circumstances but ensuring the Patient is not left alone at any time_
3.A review is required on how training of 1: 1 (one to one) care is implemented And administered on a hospital ward and also how such training is communicated to nurses and Carers ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and believe you ANDIOR your organisation have the power to take such action. It is for each addressee to respond to matters relevant to them: The manufacture and design of bed rails should be reviewed and changed as and when appropriate_
2. the Definition of 1:1 (one to one) care needs to be reviewed and all the rules relating to this care should be reviewed and modified where necessary
3. The Training of 1:1 (one to one) care should be reviewed and modified where appropriate.
4. How 1:1 (one to one) care is communicated to nurses and Carers on the hospital wards needs review and where appropriate modified. May falling they

YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report: !, the Assistant Coroner; may extend the period: Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise you must explain why no action is proposed. COPIES and PUBLICATION have sent a copy of my report to the Chief Coroner and to the following Interested Persons The Chief Executive Officer; The St George's University Hospitals NHS Foundation Trust of Blackshaw Road, Tooting, London SW17 OQT The Chief Executive Officer, The Nursing and Midwifery Council of 61 Aldwych, Holborn, London, WCZB 4AE The Chief Coroner of England & Wales_ His Honour Judge Mark Lucraft WC _ Room C09, Royal Courts of Justice, Strand, London; WCZA 2LL. Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. You may make representations to me, the Assistant Coroner; at the time of your response, about the release or the publication of your response by the Chief Coroner. 14 January 2020 Q4 6 l Russell Caller HM Assistant Coroner Inner West London Westminster Coroner's Court 65, Horseferry Road London SWIP 2ED The