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.
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