A Liverpool coroner has sent a prevention of future deaths report to the care home
Westwood Hall Nursing Home.(Image: Liverpool Echo)
A “tiny and frail” pensioner who died after breaking her neck at her care home was deemed a “low risk” of falling. Dorothy Ann MacDonald, 86, sustained a fractured neck of femur as a result of an unwitnessed fall in the bedroom of Westwood Hall Nursing Home, near Brimstage, on August 11 this year.
Ms MacDonald was taken to nearby Arrowe Park Hospital where it was determined by clinicians that she was not fit enough to undergo surgical repair of the fracture because of her underlying health. She was placed on end of life care and died at the Wirral hospital on August 22 from multi-organ failure brought about by the fracture.
An inquest heard earlier this month that Ms MacDonald was “tiny and frail” on arrival at the nursing home after being discharged from hospital following a three-month spell. She was said to have had a “very poor short-term memory” and did not know why she was in the care home.
Her previous medical history included dementia as well as atrial fibrillation and chronic kidney disease. The care home said Ms MacDonald was at high risk of falls. But despite the pensioner already having fallen at the home and had tried to move alone without a trolley, staff at the home documented her risk of falling as “low likelihood”.
It was later reassessed and increased to medium risk, but a coroner found this to also be wrong. The coroner also said he was not satisfied that the risk assessment training was effective or had been adopted properly.
The ECHO has approached Westwood Hall Nursing Home and its parent company SpringCare for comment about the incident.
After the inquest concluded, David Lewis, assistant coroner for Liverpool and Wirral, sent a public prevention of future deaths report to the care home.
He said: “The deceased died as a result of the fractured neck of femur she sustained in a fall at the care home. It ought to have been understood by nursing or other senior staff in a nursing home setting that such an injury would be of great seriousness in somebody presenting as the deceased did, with a fatal outcome following hospital admission after such an injury not being uncommon.
Westwood Hall Nursing Home(Image: Liverpool Echo)
“The court was told that such risk assessments might be made by any nurse, the deputy manager or the home manager, and that all had received relevant training. The court is not satisfied that the training was effective and/or was being adopted properly.”
He said that the risk assessment “probably did not make a difference to control/mitigation measures put in place, but the court is concerned that underestimation of an individual’s falls risk could place other residents at risk of falls which might threaten their lives”.
The coroner added: “The court would like to know what steps are being taken to ensure that all relevant staff have received, understood and consistently act upon suitable and sufficient training in the assessment of falls risk.
“In addition, the court was shown that the nursing home’s fall policy indicated that it is good practice to refer cases of falls to the ‘falls team’, but that in practice this was done rarely, partly because the home manager lacked confidence in the responsiveness or value of the service. She said that the policy did not specify how many falls should take place prior to a referral.
“The court would like to know how the nursing home will satisfy itself: (a) that all relevant staff have received, understood and consistently act upon suitable and sufficient education about the circumstances in which, and how, a referral to the falls team should be made; (b) that the service is sufficiently responsive and effective in responding to requests for its specialist input.”
The care home has until February 11, 2026 to respond to the report.