John Lowe
PFD Report
Historic (No Identified Response)
Ref: 2015-0132
Coroner's Concerns (AI summary)
Nursing staff incorrectly believed 1:1 care could not be provided for falls risk alone, only for mental health needs, regardless of a patient's physical care requirements.
View full coroner's concerns
1. That there was a belief amongst members of the Trust’s nursing staff that they were unable as a matter of policy to provide 1:1 nursing care for a patient in respect of that patient’s falls risk assessment alone, no matter what that assessment might be.
2. That there was a belief amongst members of the Trust’s nursing staff that 1:1 nursing could only be provided on the basis of a patient’s particular mental health needs, and not in respect of his or her physical care needs.
2. That there was a belief amongst members of the Trust’s nursing staff that 1:1 nursing could only be provided on the basis of a patient’s particular mental health needs, and not in respect of his or her physical care needs.
Sent To
- Nottinghamshire Healthcare NHS Trust
Response Status
Linked responses
0 of 1
56-Day Deadline
1 Jun 2015
About PFD responses
Organisations named in PFD reports must respond within 56 days explaining what actions they are taking.
Source: Courts and Tribunals Judiciary
Report Sections
Investigation and Inquest
The death of John Lowe was subject to an Inquest from 23rd to 25th March 2015.
Circumstances of the Death
John Lowe was an inpatient in wards controlled by the Trust for mental health assessment and care following his suffering a stroke on 7th January 2014. He had been transferred to the Trust from medical wards controlled by Nottingham University NHS Trust, where he had been assessed as being at high risk of falls and had been provided with 1:1 nursing as a result of such assessment. Whist on mental health wards in the care of the Trust he suffered a series of falls, the final one of which, on 18th February 2014, caused him to sustain a fractured left neck of femur. This injury made a material contribution to his eventual death from bronchopneumonia on 26th February 2014.
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.