An elderly woman who suffered three falls in three months at a care home was not risk-assessed correctly, an inquest has revealed.
Dorothy Reeves, aged 87, died at Sandwell General Hospital in October 2013, after being admitted following a third fall at Dingle Meadow residential home.
Mrs Reeves, who suffered from dementia, died from hospital-acquired pneumonia on October 13. Mrs Reeves was found on the floor of her bedroom at the home on Goldencrest Drive on October 9.
Mrs Reeves, who walked with a frame, had moved into the care home in April and suffered her first fall in August, her second in September and her third fall in October. At the Smethwick Coroners Court inquest, senior coroner Mr Balmain questioned Linda Bryant, manager at the residential care home about standards of care at the home and the house manager admitted that after Mrs Reeves fell in August, risk assessments were missed. Mrs Bryant said: “Staff have since received training and we have improved our services. I am not making excuses but it was quite a difficult time.”
The inquest also revealed that after her second fall, the falls service team were not contacted by the care home and Mr Balmain called this ‘another oversight’. Mrs Bryant admitted that had the monthly assessments been completed, Mrs Reeves would have been classed as high-risk and checks would have been increased to every 30 minutes.
Mr Balmain said: “Mrs Reeves was living in the care home with reduced mobility and dementia. She suffered a number of falls. I have to say that the records are not, as admitted by Mrs Bryant, completed as they should have been and assessments should have been done after her first fall. I understand the difficulties of paperwork but netherless it is important.”
Both her sons, Gregg and Jason Reeves, attended the inquest and described their mother’s records as ‘chaotic’ and ‘incomplete’.
Mr Balmain said that Mrs Reeves died from hospital-acquired pneumonia and recorded accidental death.