BEECHWOOD LODGE Response to regulation 28 issued by Mrs Robinson Coroner resulting from concerns raised at the inquest of Beryl Walsh (deceased) Completed by CONCERN ACTION TAKEN BY WHOM /WHEN Multiple missed opportunities to identify the person The falls that BW sustained was over a 3 All actions have was at high risk of falls and to escalate her care by and half vear period, the equipment what been completed way of a referral to falls prevention, multiple would be usually required was more of a with immediate opportunities to provide the correct falls prevention risk to BW due to extremely poor eyesight effect by Home equipment: so equipment for falls prevention was not Manager Concern that appropriate action to minimise the appropriate due to trip hazards, however risks of deaths occurring in similar circumstances has BW had good capacity so was able to use been taken by beechwood_ the call bell she had in place when she required assistance: We have more in robust risk assessments for residents who have had falls. 2 We are documenting all conversations with relatives and professionals We have now all new risk assessments in all care plans about safety equipment whether they use it or the reasons why do and the reasons why they don't also have in place a falls matrix, so | can monitor falls and do referrals to falls team when required: We will ensure all falls risk concerns are referred to appropriate professionals i.e. doctors falls teams BW' s falls dates are as follows, 1st fall 2015 2nd fall 2016 3r fall 2017 4th 5th 6th fall in 2018 put put they put and