John Bird

You were unable to detail in court the entirety of the falls risk assessment you had undertaken for Mr Bird, because you did not bring the record of the risk assessment to the inquest, despite the nature of Mr Bird’s death and a written request from my coroner’s officer.

However, you were confident that you had assessed Mr Bird as being at very high risk of falls, as a consequence of his level of cognitive impairment coupled with his ability to walk without assistance. (This is, of course, a very difficult combination.)

Yet the carer who found Mr Bird after his fall, did not appear to have any familiarity with risk assessments. Even allowing for possible language difficulties (the carer is not a native English speaker), he assessed Mr Bird’s ability to mobilise unaided as “fine”, and did not see any particular risks for him.

When I put the carer’s evidence to you in court, you told me that he should know about the risk assessments. You later agreed in evidence that, as manager of the care home, it is your responsibility to ensure that all staff are familiar with risk assessments and the resulting care plan for each resident.