Fall training warning after care home death

Christina Betty Dawson died after a fall at Darnall Grange Nursing Home in Sheffield

A coroner has warned about a lack of clear training connected to care home falls among agency staff after an elderly woman died while at a Sheffield nursing home.

Christina Betty Dawson, who died aged 94 in March, fell at least 10 times while a resident at Darnall Grange Nursing Home.

Senior coroner Tanyka Rawden, who covers South Yorkshire, said agency nurses weren't trained on a policy not to move a resident after a fall due to the risk of exacerbating injuries.

When approached, Darnall Grange made no comment except to say all matters had been addressed.

Ms Dawson, who required a walking frame to get around, moved to the care home on Poole Road in May 2020.

She was described as being of high-risk for falls, which was initially managed with a low bed, according to the Local Democracy Reporting Service.

The coroner said Ms Dawson suffered six falls between 2022-2023 and was admitted to hospital several times.

"Darnall Grange felt they could not accommodate her within their residential unit any longer and a nursing placement was required," the coroner said in a prevention of future deaths report.

"The funding for this was declined and Darnall Grange accepted her back onto their residential unit despite accepting they could not manage her falls risk."

'Risk of future deaths'

Ms Dawson fell twice on 16 March 2024 and suffered a fractured femur, but was moved into her bed by an agency nurse who did not know the home's policy of not moving a resident after a fall.

"It cannot be said whether the fracture was caused by the fall or by Betty being moved after the fall,” Ms Rawden said.

Ms Dawson died in hospital three days later, with the cause of death recorded as a femur fracture and frailty of old age, vascular dementia and heart failure.

The coroner heard it was presumed from agency staff's nursing training they would know not to move a resident after a fall.

She concluded: “There is a clear risk of future deaths will occur if agency staff are not provided with home-specific training, policies or procedures."

The home had made several changes since, the coroner added, including not admitting patients at high risk of falls.

Listen to highlights from South Yorkshire on BBC Sounds, catch up with the latest episode of Look North or tell us a story you think we should be covering here.