Coroner warns care home of ‘cultural problem' after patient's double bed fall

Independent

2 days ago

A coroner has told a care home it suffers from a 'cultural problem' after a patient died shortly after falling from her bed twice in the space of a week.
Sonia Sore, 84, fell onto the floor at North Court Care Home in Bury St Edmunds, Suffolk, on October 14 2023 after the right handrail on her bed was not raised.
Despite staff subsequently noting that the rails should be raised when the patient was occupying the bed, she fell out the same side in the same manner six days later after no action was taken.
A bleed was then identified on Mrs Sore's brain after her condition deteriorated and she was taken to hospital.
She died on November 8 2023 after receiving palliative care from the care home.
Mrs Sore had been assessed as at risk of falling from her bed prior to either of the falls due to earlier health issues causing reduced mobility, with the raising of bed rails included in a management plan to address this risk.
A narrative conclusion given at an inquest into her death found it was not possible to identify when the bleed on Mrs Sore's brain first started, but that it was probable the second fall on October 20 had 'made a material contribution' to her injury and death.
'The fact that the right-hand bed rail was not raised on Mrs Sore's bed meant that she was able to fall out of bed on the 20th October 2023 and this fact made a material contribution to the death,' it added.
The inquest concluded Ms Sore died due to accidental causes. Her medical cause of death was given as a subdural haematoma.
A nurse at the care home made an entry in Mrs Sore's notes confirming the requirement for her bed rails to be raised on October 17, but the right handrail was not raised following the note and was not raised at any point between the two falls.
Darren Stewart OBE, area coroner for Suffolk, said it was apparent during the inquest that North Court Care Home had 'a less than diligent focus' on risk assessment and mitigation.
He said: 'Despite risks being assessed, and mitigation measures identified, staff would regularly fail to implement the latter.
'In Mrs Sore's case this included the failure to secure the right hand side bed rail as identified in numerous risk assessments relating to mitigating her risk of falling from the bed.
'The evidence indicated that this applied in relation to the actions of multiple staff at the care home, not just a few, giving rise to the concern that this was a cultural problem at North Court Care Home.'
A copy of a prevention of future deaths report were sent by the coroner to the care home's director of operations, with Mr Stewart adding: 'I believe you (and/or your organisation) have the power to take such action.'
Copies were also sent to Mrs Sore's family, the Care Quality Commission, Mrs Sore's GP practice and the Chief Coroner for England and Wales.