Robert Howell: Care home ordered to prevent further deaths after resident, 91, died after fall
Robert Howell had been living at Elm Tree Court in Hull for two months when he died.
Mr Howell had a history of falls, and fell twice on April 10 and April 11.
Staff were not informed by management that he had a history of frequent falls, and in the early hours of April 12, his sensor mat on his bed activated, indicating he had got out.
A carer went into his room and found him standing by his bed, but did not ask him to sit on his bed.
Moments later Mr Howell stumbled backwards and struck his head, and he died eight days later in hospital from complications linked to a hemorrhage.
Following an inquest into Mr Howell’s death, Lorraine Harris, area coroner for East Riding of Yorkshire, has now written to the home to demand answers on how future deaths will be prevented.
She wrote: “Team Leaders held handovers between themselves, it was then up to the individual Team Leader to decide what to pass on to the staff responsible for caring.
"It became apparent during evidence that often vital caring and risk needs were not always cascaded to the staff interacting with the residents.
"As such vital information to those responsible for providing care was often not provided.”
Ms Harris said care plans for each patient had not been read by all carers and “no time was set aside for staff to familiarise themselves with the care plan or individual needs and risks of the residents.”
"It was acknowledged that the home did have procedures introduced
since Mr Howell’s death however it became evident that there was still a
breakdown in communication and vital information was not being
shared. There appeared to be a lacuna in what information should be
passed to all staff and how confirmation of understanding was checked,” Ms Harris wrote.
The home now has until November 16 to respond with how it will prevent future deaths.
Elm Tree Court care home was approached for comment.