Worcester care home told to act after resident's death
Mrs Fortey - whose age was not referenced in the report - suffered the fall shortly after midnight on 25 September before carers came and assisted her.After an examination they concluded she had not injured herself and they opted not to seek any medical attention, according to the report.No medical attention was sought until shortly before midday on 27 September when she was recorded as not being able to support her own body weight.On 29 September, Mrs Fortey underwent a hemiarthroplasty procedure to repair a fractured hip sustained in her fall. She was transferred to Kidderminster Hospital to continue her rehabilitation but on 14 October she became increasingly frail. Despite treatment, she continued to decline and on 5 November died of natural causes, with injury sustained in the fall contributing to her death, as recorded by Mr Reid in an inquest on 18 June.
Matters of concern
As well as missing opportunities to have Mrs Fortey examined by medical professionals, Mr Reid also criticised the home for failing to document their resident's fall. He said the then care home's manager was informed of the incident and later on 25 September reviewed Mrs Fortey's care plans but at "no time did she pick up on the fact that no account of the fall was contained" in the file. Mr Reid also highlighted that Mrs Fortey's notes referred to her as being able to "mobilise independently" but after the fall she was described as "having bad mobility". In his report, he said: "Despite these obvious changes in her condition, no member of staff identified that these changes might have been due to the fall." The then care home manager had told Mr Reid that although she had been in the role since 13 August, she was still not familiar with the care home's records system.She explained she was unable to scroll through residents' notes, and was instead just "muddling through".Mr Reid concluded his report and said of the site "action should be taken to prevent future deaths".
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