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Investigation and inquest
On 04/08/2021 I commenced an investigation into the death of Reginald Howard Weston. The investigation concluded at the end of the inquest. The conclusion of the inquest was Accident
Circumstances of the death
Mr Weston died due to injuries sustained in a fall on 7 July 2021. It was identified in evidence that he had moved and bypassed the sensor mat that had been placed at his feet and that care staff were aware he had done so on previous occasions. Although the presence of an in-place sensor mat unlikely made a difference in Mr Weston’s fall, it may do so in different circumstances where a resident is known to bypass the sensor mat. He had fallen twice on 4 July 2021 but there was no evidence to indicate his falls risk assessment was reviewed following those falls and recorded as required by the Majesticale Falls Management Policy and Procedure.
Coroner’s concerns
Evidence was given in relation to the Majesticale Falls Management Policy and Procedure requirement to record a review of the resident’s risk assessment in the context of 2 recorded falls on 4 July 2021.
Blenheim House management need to consider:
a) Documentation demonstrating a review of the resident’s risk assessment has taken place following a fall
b) Timely process for completing it
Information checked against the published report and official responses