Sylvia Savage died on April 25, 2023, at University Hospital North Durham having fallen from her bed at the Redwell Hills Care Home in Consett, County Durham a month earlier.
An inquest into her death heard the fall, on March 18, “commenced a decline in her health which, despite medical treatment and care, led to her death”.
It was the second time the 84-year-old had fallen in two months, having previously fallen on February 1, but the care home never recorded that fall, and her daughter was left to report it to the GP, the inquest at Crook Coroners’ Court heard.
She had a sensor mat beside her bed designed to alert staff when she tried to move, but despite her being known to move it or unplug it there was a “lack of thought as to an alternative measure”, Assistant Coroner James Thompson said.
He added: “Given the second fall Mrs Savage had some weeks later gave her injuries that led to her death this approach appears flawed.”
Filing a prevention of future deaths report, Mr Thompson, outlined how that previous fall “should have prompted staff to return to [Mrs Savage’s] care plans and re-evaluate them”, but they did not, before she died as a result of her fall in March.
The document, known as a Regulation 28 report, also outlined how no electronic records were kept at the home, and how falls were not always reported.
The inquest heard there was no clear definition of when to report falls externally and internally.
Mrs Savage’s call on February 1 was not recorded internally, but was reported to the Care Quality Commission.
The fall on March 18 was not reported to CQC
The Coroner said: “This seems an occurrence worthy of reporting— it strikes me some clearer reporting structure is necessary.
“Without access to good records, I can see a clear risk to the care of residents.
“It is also surprising to me the complete reliance on paper records which have in Mrs Savage’s case have been lost.
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“I would have expected to see electronic recording of information and electronic storage of it. I note the roll out of this in the company has been paused whilst the company is awaiting sale and my concern is whether the electronic recording and storage will be implemented – to me immediate access to records of a resident or the absence of them creates a concern.”
The care home operator, Four Seasons Healthcare, will now have until February 12 to respond to the Coroner outlining how it will take action.