_ (1) At the Inquest was told that on Emerald Ward the Nursing staff have a higher awareness of the risk of falls because s0 many f their patients are at high risk However_ provide no specialling Presumably the rationale for this is that are extremely good at their job and are able to take care of their patients without specialling: Demonstrably in Mrs Webb's case this did not happen: (2) There was a plan in mid-September put in place by the Dementia Nurse for Mrs Webb to have increased levels of observation, for her to be engaged in meaningful activity and for allowing her to be mobile but using non slip footwear and a mobility aid. With regard to the observations really could not see any evidence that this was giving her enhanced protection. When analysing the falls and their timing it was clear that always happened early in the morning and often round about the end of the night shift and the start of the shift when clearly this particular lady was more vulnerable because suppose she was more active , possibly also if she had been in bed for most of the night she might have been less safely mobile_ Its a shame that this pattern was not observed and arrangements put in place to keep a particular eye on her around this period of time_ With regard to meaningfuLactivity it never appeared in the notes following the mid-September plan and since it wasn't in the notes found no evidence that it happened. would suggest that on each change of shift the meaningful activity which the patient has engaged in is recorded and noted so that if there is something that he or she finds particularly absorbing this activity can be offered at times of particular vulnerability. Withregard_to mobilising, appreciate that the wandering patient who is mobile is at particular risk and also appreciate the difficulty that might be encountered when trying to persuade such a patient to use a mobility aid_ Non slip footwear however; is surely much easier to provide: know that the hospital footwear comprises 'short socklets' in different sizes (thus the right size is always difficult to obtain) with non-slip soles. was told that these can shift round on the foot so that the sole perhaps rides round to the_top of the foot meaning_the socklet then becomes dangerous City they they they day fully

VERONICA HAMILTON-DEELEY