Coroner Mandates Action at Care Home Following Fatal Fall

A coroner has instructed a care home to address its resident observation protocols following the death of a man who fell from his bed. John Riley, aged 73, was discovered on the floor of his room at The Manor House in North Walsham, Norfolk, and succumbed to a neck fracture at the location on February 9. An inquest held last week revealed that Mr. Riley was scheduled for observations every two hours, yet he had not been checked between 03:00 GMT and 05:25, when he was found on the floor. In a report aimed at preventing future deaths, senior coroner Jacqueline Lake expressed concerns, citing evidence that Mr. Riley’s observations had been delayed on 10 occasions during January. She further noted that The Manor House had undertaken “some action” to reduce the frequency of late observations. However, the inquest also heard that certain checks were still being conducted beyond the designated two-hour interval. Mr. Riley had resided at the facility since 2017, requiring assistance with his care due to life-altering injuries sustained in a 1976 car crash. He was assessed as having a low risk of falling from his bed, which was positioned at its lowest setting. During the inquest, it was disclosed that he was found with the bed frame beneath his neck. The Manor House is obligated to provide a response to the report within 56 days. Healthcare Homes has been contacted for comment.