Bromford Lane Care Home

Wider context from the report

“1. The evidence of ████████ suggested that proper skin inspections and skin monitoring were not carried out between 14th to 18th March 2021 as, had they been carried out, they would have been documented and recorded in detailed body maps. 2. The evidence of ████████ suggests that skin inspections were carried out but were not recorded. It was admitted by ████████ in evidence that there was a failure to keep proper and adequate records by staff. 3. At inquest I found that, on the balance of probabilities, inspections were carried out but observations were not recorded and records were not kept. 4. It was unclear whether this was a "one-off" incident or whether it reflected a systemic issue. On reflection, the fact that records were not taken or kept over a period of four consecutive days (as opposed to one isolated day), is indicative of a systemic issue that staff are not ensuring that their observations are correctly and adequately recorded. 5. It is clear that a failure to ensure that there is a correctly working system of record taking poses a risk of future deaths occurring, especially in the context of extremely frail and vulnerable adults/residents who in a position of dependency by virtue of their frailty or vulnerability. ”