Source · Prevention of Future Deaths

Nellie Travis

Ref: 2014-0101 Date: 5 Mar 2014 Coroner: John Pollard Area: Manchester (South) Responses identified: 0 / 1 View PDF

The hospital's Falls Risk Assessment tool is ineffective due to its subjective nature and inconsistent application by nursing staff, highlighting the need for a more objective assessment method.

Date 5 Mar 2014
56-day deadline 30 Apr 2014 est.
Responses identified 0 of 1
Hospital Death (Clinical Procedures and medical management) related deaths

Coroner's concerns

AI summary
The hospital's Falls Risk Assessment tool is ineffective due to its subjective nature and inconsistent application by nursing staff, highlighting the need for a more objective assessment method.
View full coroner's concerns
During the course of the evidence was told that there is a Falls Risk Assessment tool used by the hospital; but in this case it had been completed and assessed by a 'bank nurse' who was not an employee of the Trust: The evidence given by the senior member of the nursing staff was to the effect that the operation of the Falls Risk Assessment Tool is very subjective and depends upon an individual opinion of the nurse completing it as to how high the falls risk is shown to be. It was agreed that such a document is of very little use at all and that a more objectively assessed tool needs to be adopted.

Report sections

Investigation and inquest
On 14th October 2013 commenced an investigation into the death of Nellie Travis, date of birth 13th March 1927 The investigation concluded on the 28th February 2014 and the conclusion was Accidental Death: The medical cause of death was 1a Haemorrhagic cerebral infarction and 2 Pneumonia, fractured neck of femur sustained following a fall, chronic bronchitis and emphysema, idiopathic anaemia_
Circumstances of the death
She was admitted to hospital for the problem of her anaemia. On the 2nd October 2013 she was rising from her bed in the hospital ward when she fell and broke her hip.
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. It is essential that full information is passed promptly to the GP practice of a patient discharged. being

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Report details

Reference
2014-0101
Date of report
5 March 2014
Coroner
John Pollard
Coroner area
Manchester (South)

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: 30 Apr 2014 (estimated).

Sent to

Tameside Hospital NHS Foundation Trust

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