On 17/07/15 commenced an investigation into the death of Allan Richard Beasley_ The investigation concluded at the end of the inquest on 22/10/15. The conclusion of the inquest was: The deceased died from a traumatic cervical spine fracture following 7 falls_ The initial risk assessment was inadequate. There was a failure to correctly document the falls as they occurred, The risk assessment was not updated and there was no referral to the falls team for further assessment These failures contributed to his death _

The deceased suffered from vascular dementia. He was admitted to Sunrise care home on 21/05/15 as he could no longer manage at home_ An initial moving and handling assessment confirmed that he could mobilise with 2 sticks but he needed supervision: He was noted to be unsteady on his feet at times. After admission he had a number of falls_ 03/06/15 at 15.00 the deceased was walking to the lounge with his son and lost his balance and fell with no injuries_ 13/06/15 the deceased had two falls_ At 08.30 he was found on the bedroom floor shouting for help and he had grazed his right forearm At 09.30 he was found on the floor with a skin tear to the right wrist: 17/06/15 at 12.00 he was found on the floor in the corridor with no injuries. 22/06/15 no incident form but the deceased was noted to have been found on the floor near his bed and had defecated on the carpet 29/06/15 no time recorded He was walking alongside another resident when there was some sort of altercation with that resident and the deceased fell and grazed his head and bruised his eye. The incident was reported to the police and no further action taken. On 04/07/15 he suffered a further unwitnessed fall in the dining area: He was admitted to Birmingham Heartlands Hospital the same day: A CT scan confirmed C1 burst cervical fracture and a fracture of the odontoid process named as a type 2 odontoid peg fracture. He was treated with a collar but due to his vascular dementia he kept removing the collar_ He developed a chest infection. He continued to deteriorate and passed away on 09/07/15 An external review after the events confirmed the following: The initial risk assessment did not indicate all the risk factors which may contribute to falls_ There is no evidence the initial documents were ever reviewed or that the deputy manager was aware of the number of falls Staff failed to follow the falls prevention policy failed t0 correctly record and and incidents_ The monthly wellness check was not completed at the end of June 2015, and the monthly falls analysis log was not completed. An uneven floor may have contributed to the fall