Ethel Cross

and 22nd_ aged 22na end years.

At the conclusion of the inquest; indicated to the Properly Interested Persons that proposed to write to the Trust by way of a report in accordance with the provisions of paragraph of Schedule 5 of the Coroners and Justice Act 2009. During the Inquiry, received evidence that chairs Utilised by staff which have wheels attached to them had been present on ward 4 and that Ethel Cross had sat on one of these chairs which slipped and she suffered a fracture_ heard evidence that these chairs have been removed from two wards including on which elderly patients at significant risk of falls may be cared for. am concerned that such chairs may continue to be present on other wards within the Trust where such patients may have access to them and similar incidents may occur. During the course of the evidence heard that although at high risk of falls, and someone who would need one to one assistance from staff when mobilising; Ethel Cross was not provided with an alarm that in the event of her moving when staff are not nearby could alert members of the medical staff to such movement allowing the staff to attend to her. All such alarms on the ward were in use and such alarms are rarely not deployed. Having concluded this inquest, now write to the Trust to confirm that in my view the Trust should take action because: the presence of such chairs with wheels attached - in an area frequented by elderly patients may lead to further such fatalities should elderly patients access them patients who are at high risk of falls may try t0 mobilise themselves unsupported when staff are busy elsewhere on the ward with other patients and all of the available alarms are in use would therefore be obliged if the Trust would write to me in due course to confirm what steps if any the Trust proposes to take to address_these _two areas of concern