This page connects the concerns raised in this report with statements found in recipients’ published responses. A link shows a clear evidence connection; it does not assign responsibility.
On 8th April 2015 an Inquest into the death of Elsie Marjorie Brown was opened, and it was resumed on 30th November 2015, concluding on 4th December 2015.
Circumstances of the death
Mrs Brown fell from her bed at Langwith Lodge Residential Care Home on 23rd March 2015 and suffered a fractured left humerus and right hip. She died on 5th April 2015 at Chesterfield Royal Hospital as a result of bronchopneumonia and lobar pneumonia, which developed as a result of these fractures.
Coroner’s concerns
1. There was no falls risk assessment nor bed rails assessment in place for Mrs Brown, nor was her mental capacity assessed. 2. Mrs Brown’s care plan was incomplete, unsigned, undated and never reviewed, despite Mrs Brown falling from her bed on 8th March 2015. 3. No referral was made to the Falls Team nor (by Langwith Lodge) to Derbyshire Community Health as regards the question of bed rails. 4. There was a lack of clarity as to where the responsibility for an initial bed rails assessment lay. 5. There was an insufficiently robust auditing process, in that the omissions were not identified by Langwith Lodge nor by Your Health Ltd. 6. Mrs Brown’s fall on 23rd March 2013 was not handed over, nor recorded nor reported, and there was a lack of clarity amongst staff as to where responsibilities for these matters rested. 7. A member of staff who had responsibility for record making could not effectively and independently do so due to poor literacy skills. 8. That the night time provision of two staff members to cover the main Lodge and two to cover the Horton Suite (two separate but joined buildings) was not seen as a minimum requirement to ensure the health and safety of residents when at least one resident in each building needed the assistance of two carers, but that only three were regularly rostered for the night shift. 9. Handovers were not regarded as integral to the staff’s paid shift and were informal and unpaid.
Concerns and recipient responses
Select any concern, action or position to view the source wording.
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a recipient says it has done, is doing, or plans to do in response to a concern raised.12
Action
Use a multifactorial falls risk assessment covering nighttime risks.
Stated byYour Health LimitedStated completedThe respondent said that this action was complete when they made their response on 4 December 2015.
Action
Improve recording and follow-up of bed-rail referrals so outstanding referrals are flagged.
Stated byYour Health LimitedStated completedThe respondent said that this action was complete when they made their response on 4 December 2015.
Action
Introduce company-wide basic literacy and numeracy testing, providing additional support and guidance where needed.
Stated byYour Health LimitedStated plannedThe respondent said that this action was planned when they made their response on 4 December 2015.
Action
Introduce a staff handover document recording daily responsibilities and identifying the senior person in charge.
Stated byYour Health LimitedStated completedThe respondent said that this action was complete when they made their response on 4 December 2015.
Action
Use a falls management folder containing assessment tools, including a bed-rail risk assessment and algorithm.
Stated byYour Health LimitedStated completedThe respondent said that this action was complete when they made their response on 4 December 2015.
Action
Clarify Horton Suite admission criteria to restrict admission to reasonably independent, low-falls-risk residents.
Stated byYour Health LimitedStated completedThe respondent said that this action was complete when they made their response on 4 December 2015.
Action
Train remaining key personnel on required procedures and resident documentation, with systems to monitor, audit and review effectiveness.
Stated byYour Health LimitedStated completedThe respondent said that this action was complete when they made their response on 4 December 2015.
Action
Provide a minimum of four staff across the building when a Horton Suite resident requires support from two carers.
Stated byYour Health LimitedStated plannedThe respondent said that this action was planned when they made their response on 4 December 2015.
Action
Alter shift patterns to create overlap for a protected, paid handover.
Stated byYour Health LimitedStated completedThe respondent said that this action was complete when they made their response on 4 December 2015.
Action
Employ a Quality Manager to audit care homes, monitor managers’ auditing, and address omissions through quality-improvement action plans.
Stated byYour Health LimitedStated completedThe respondent said that this action was complete when they made their response on 4 December 2015.
Action
Use a care plan matrix assigning responsibility for reviewing individual care plans and monitor staff compliance.
Stated byYour Health LimitedStated completedThe respondent said that this action was complete when they made their response on 4 December 2015.
Action
Clarify staff responsibility for initial bed-rail assessments and verify completion through care-plan audits.
Stated byYour Health LimitedStated completedThe respondent said that this action was complete when they made their response on 4 December 2015.
Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.4
Position
The staff member’s literacy was considered adequate because records showed they had passed a basic literacy test and an accredited care qualification.
Stated byYour Health LimitedDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
Position
A formal capacity assessment was not considered necessary because capacity was presumed unless evidence showed that Mrs Brown lacked capacity.
Stated byYour Health LimitedDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
Position
Four night staff were not considered routinely necessary because the two areas formed one linked building and staffing levels were based on residents’ dependency.
Stated byYour Health LimitedDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
Position
The local health service was responsible for providing bed rails, with an occupational therapist or district nurse deciding whether they could be used.
Stated byYour Health LimitedRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
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Information checked against the published report and official responses