Source · Prevention of Future Deaths
Nellie Travis
Ref: 2014-0101
Date: 5 Mar 2014
Coroner: John Pollard
Area: Manchester (South)
Responses identified: 0 / 1
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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
Coroner's concerns
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