Elsie Brown
Disputed
Langwith Lodge states that corporate documentation and procedures for mental capacity assessment have been in place since 2010. They found evidence of a referral request after Mrs Brown's first fall and state staff knew correct procedures but chose not to follow them for her second fall, indicating existing robust training. (AI summary)
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Dear Miss S Haskey
We would like to thank you for the time and attention you have given to the Inquest into the death of Mrs Elsie Brown, who resided at Langwith Lodge Residential Home, Mansfield NG20 9ES.
We make the following response to the Regulation 28
1. There was no falls risk assessment nor bed rails assessment in place for Mrs Brown, nor was her mental capacity assessed.
The Company appointed an independent consultant in December 2015 to carry out an investigation into matters that had come to light during the course of the inquest. Part of this investigation looked into why this, and other corporate documentation was not used as part of Mrs Brown's care plan.
The Company also, since 2010, have had corporate documentation and procedures in place to assess the mental capacity of residents. These are regularly updated, eg when there are changes in legislation. Mrs Brown's capacity was not formally assessed as it was not deemed that she lacked capacity, and the Mental Capacity Act states that capacity must always be assumed unless it is proved otherwise. Page 1
2. Mrs Brown's care plan was incomplete, unsigned, undated and never reviewed, despite Mrs Brown falling from her bed on 8th March 2015.
Following our own investigation into the earlier incident on 8th March, we have found an entry in the staff handover book from 9th March 2015 (attached) which details that a referral had been requested through Claire Byrne. We apologise that we were unable to present this at the time of the Coroner's inquest.
We would have expected a referral to have been responded to within 5-7 days, and at the time of the second incident on 23rd March 2015, no visit had been made. Page 2
6. Mrs Brown's fall on 23rd March 2013 was not handed over, nor recorded nor reported and there was a lack of clarity amongst staff as to where responsibilities for these matters rested.
The fall from her bed that Mrs Brown suffered on 23rd March 2015 was not handed over, recorded or reported due to the three staff on duty choosing not to do so. The company has established during the disciplinary process that all three staff knew the correct procedures to follow but that for different reasons they admitted not adhering to them. We have a robust induction and training programme in place to support knowledge and skills. All staff had a duty of care to ensure Mrs Brown received appropriate medical assessment and treatment. Page 3
We would like to thank you for the time and attention you have given to the Inquest into the death of Mrs Elsie Brown, who resided at Langwith Lodge Residential Home, Mansfield NG20 9ES.
We make the following response to the Regulation 28
1. There was no falls risk assessment nor bed rails assessment in place for Mrs Brown, nor was her mental capacity assessed.
The Company appointed an independent consultant in December 2015 to carry out an investigation into matters that had come to light during the course of the inquest. Part of this investigation looked into why this, and other corporate documentation was not used as part of Mrs Brown's care plan.
The Company also, since 2010, have had corporate documentation and procedures in place to assess the mental capacity of residents. These are regularly updated, eg when there are changes in legislation. Mrs Brown's capacity was not formally assessed as it was not deemed that she lacked capacity, and the Mental Capacity Act states that capacity must always be assumed unless it is proved otherwise. Page 1
2. Mrs Brown's care plan was incomplete, unsigned, undated and never reviewed, despite Mrs Brown falling from her bed on 8th March 2015.
Following our own investigation into the earlier incident on 8th March, we have found an entry in the staff handover book from 9th March 2015 (attached) which details that a referral had been requested through Claire Byrne. We apologise that we were unable to present this at the time of the Coroner's inquest.
We would have expected a referral to have been responded to within 5-7 days, and at the time of the second incident on 23rd March 2015, no visit had been made. Page 2
6. Mrs Brown's fall on 23rd March 2013 was not handed over, nor recorded nor reported and there was a lack of clarity amongst staff as to where responsibilities for these matters rested.
The fall from her bed that Mrs Brown suffered on 23rd March 2015 was not handed over, recorded or reported due to the three staff on duty choosing not to do so. The company has established during the disciplinary process that all three staff knew the correct procedures to follow but that for different reasons they admitted not adhering to them. We have a robust induction and training programme in place to support knowledge and skills. All staff had a duty of care to ensure Mrs Brown received appropriate medical assessment and treatment. Page 3