Mrs Freda Cordy died on the 1®' November 2015. An investigation was opened on 11* November and was concluded by way of an inquest on 13th April 2016. The medical cause of death was: la) Subdural haematoma b) Head injury 2 Hypertension, Ischaemic heart disease, dementia. A conclusion of accidental death was returned.

Mrs Cordy was a 93 year old frail lady with multiple diagnoses including dementia. On the s"' August 2015 Mrs Cordy was admitted to the Emergency Assessment Unit at Northampton General Hospital following a fall at her home address. Mrs Cordy had a history of previous falls. The medical team identified a need for constant supervision. A multiple disciplinary meeting including Social Services and the health partnership team decided that Mrs Cordy should be placed into Templemore Care Home. On 1®' October 2015 Mrs Cordy was admitted to the care home, requiring full support for all personal care tasks. Despite the need for constant supervision that had been identified, the care home was only able to offer 2 hourly checks. No specific falls risk assessment was undertaken. Mrs Cordy fell from her bed at the care home on 2"'' October 2015 suffering an extensive subdural haematoma. After a short stay in hospital, Mrs Cordy returned to Templemore Care Home on 7^^ October 2015 at which time a falls risk assessment was undertaken resulting in a mattress being placed beside her bed. On 15th October 2015 Mrs Cordy suffered a further fall from her bed at the care home suffering bleeding from her head. Mrs Cordy was then readmitted to Northampton General Hospital where she passed away at 7.13am on 1®* November 2015 as a result of the injuries sustained in the falls.