Flaws in care plan of woman who died after fall

The care plan of a woman should have been re-evaluated after the first of two falls in a care home, a coroner has said.

An inquest found Sylvia Savage, 84, died as a result of the second fall at the Redwell Hills Care Home in Consett, County Durham.

Assistant coroner for County Durham and Darlington, James Thompson, said there was a risk of future deaths at the care home if action was not taken.

Four Seasons Healthcare Group, which operates the facility, said it had noted the coroner's concerns and was working "transparently" with the authorities.

"The safety and wellbeing of our residents is our utmost priority," a spokesperson said.

"We are working transparently with the relevant authorities and our thoughts are with Mrs Savage's family."

Mrs Savage died in hospital from bronchopneumonia in April 2023.

Her death was the consequence of a fall from her bed, which happened on 18 March 2023 and started "a decline in her health", an inquest found.

A document published by the coroner this week, known as a prevention of future deaths report, said a previous fall Mrs Savage had on 1 February 2023 should have "prompted staff to return to the care plans and re-evaluate them", but it did not.

The report said it was known a sensory mat was not an efficient way of monitoring Mrs Savage when she tried to move, but no alternative measure was put in place.

"Indeed one care home witness stated as Mrs Savage had not had three falls in three months, no change to her plan was needed", the coroner said.

"Given the second fall Mrs Savage had some weeks later gave her injuries that led to her death, this approach appears flawed."

The February fall was not recorded internally, although the Care Quality Commission (CQC) was notified.

The report said staff at the home did not seem to have sought medical help and a nurse only came to examine Mrs Savage after her daughter told a GP about it, which was "of concern".

The second fall in March was not reported to the CQC.

The coroner said a "clearer reporting structure" was necessary.

"It is also surprising to me the complete reliance on paper records which have, in Mrs Savage's case, been lost," he added.

"I would have expected to see electronic recording of information and electronic storage of it."

A response outlining action to be taken has to be submitted to the coroner by 12 February.

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