Finding into death of Margaret Lurline Martyr-Paterson

Contributing factors

• failure to complete incident report after first window escape on 15 February 2010
• failure to document incident on running sheet
• failure to notify family of first escape incident
• failure to escalate information about escape risk to night shift staff
• inadequate supervision of confused resident with wandering behaviour at night
• lack of window safety restrictions in low-care bedrooms
• poor communication between shifts regarding resident risk changes
• assumptions in staff competency assessment rather than rigorous verification
• staff unclear on when incident reports required for near-miss events
• CCTV system poorly positioned with separate monitors for high and low care areas

Coroner's recommendations

1. No formal recommendations made due to proactive changes already implemented by Shoreham House including: installation of wooden stopper/poles on all low-care windows limiting opening to 125mm; redesigned running sheets with explicit reference to incident reporting for absconding and near-misses; staff education sessions emphasising incident reporting requirements; updated general policies; increased night shift staffing from two to three; weekly staff newsletters requiring sign-off that staff have read them