Source · Prevention of Future Deaths
Edna Evans
Ref: 2019-0318
Date: 27 Sep 2019
Coroner: John Gittins
Area: North Wales (East and Central)
Responses identified: 0 / 1
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The care home had incomplete staff falls training, incorrectly categorised a high-risk patient as medium, and lacked a policy for reassessment following multiple falls.
Date
27 Sep 2019
56-day deadline
1 Jan 2020 est.
Responses identified
0 of 1
Coroner's concerns
The care home had incomplete staff falls training, incorrectly categorised a high-risk patient as medium, and lacked a policy for reassessment following multiple falls.
View full coroner's concerns
_ The evidence provided at the inquest indicated that staff at the home were currently undergoing training in relation to the risk of falls but that this had not been fully completed: Furthermore, although the manager indicated in her evidence that a resident who had sustained a number of falls would be expected to be categorised as "high risk" , she stated that Mrs Evans was only a "medium risk" despite the fact that she had had falls prior to admission and continued to have a number of falls whilst a resident: Coroner'$ Olfice, County Hall, Wynnstay Road Ruthin;LLIS IYN Tel 01824 708047 Drury being yet
Although there was an assessment of Mrs Evans on the 11lh of January (ie shortly after she became a resident) there is no evidence to,suggest that there was reassessment following further falls nor any apparent policy or protocol requiring this.
Although there was an assessment of Mrs Evans on the 11lh of January (ie shortly after she became a resident) there is no evidence to,suggest that there was reassessment following further falls nor any apparent policy or protocol requiring this.
Report sections
Investigation and inquest
On the 3rd of May 2019 commenced an investigation into the death of Edna Evans (DOB 8.5.26 DOD 2.5.19) The investigation concluded at the end of the inquest on the 26th of September 2019 The conclusion of the inquest was one of an accidental death, the cause of death I(a) Subdural Haematoma (b)
Circumstances of the death
The deceased had become a resident at Emral House Nursing Home on the 24th of December 2018 following a number of falls Whilst a resident there had been a number of further incidents relating to Mrs Evans between the 12th of March 2019 and the 27lh of April 2019, all of which were documented as Accident Records. The final fall on the 27th of April was unwitnessed and resulted in a significant head injury which caused her death.
Action should be taken
In my opinion action should be taken to prevent future deaths and believe you have the power to take such action.
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Report details
- Reference
- 2019-0318
- Date of report
- 27 September 2019
- Coroner
- John Gittins
- Coroner area
- North Wales (East and Central)
Responses identified
Responses identified
0 of 1
1 response not yet linked
Organisations named in PFD reports are normally expected to respond within 56 days. Deadline: 1 Jan 2020 (estimated).
Sent to
- Emral House Nursery Home