Although care staff found Mr Lawrence on the floor in his room after his fall alarm went off, they failed to identify his injuries rib injuries.
He was not taken to St Helier Hospital until three days later – his injuries led to him developing a haemopneumothorax and pneumonia and he died two weeks after the fall.
In a Prevent Future Deaths report, Assistant Coroner Anna Crawford said that during Mr Lawrence’s inquest the nursing home manager provided conflicting accounts regarding attempts to seek medical attention following his fall.
Miss Crawford also noted that the nursing home manager maintained that Mr Lawrence had not sustained the acute rib fractures whilst at the nursing home, suggesting that must have occurred after he had been transferred to hospital.
It was also noted that the nursing home records were deficient in their recording of the key events following the fall.
“In view of all of the above, the Coroner is concerned that there is an ongoing risk to current residents,” the report stated.
Mr Lawrence had been a resident at the care home since September 2020.
He was independently mobile and had been assessed as being at high risk of falls but whilst a resident he was not recorded as having having sustained any falls until the one which proved fatal.
A copy of the report was sent to Mr Lawrence’s family, The Longcroft Clinic, the Care Quality Commission and Surrey County Council’s Adult Social Care Team.
The parties have 56 days from Wednesday, August 6, to respond to the report with actions taken or planned actions.
