Evidence was given that:
Although the wrist alarm had been reported as broken and not working on the 6.1.2024, this was not replaced or repaired by the company engaged by the local authority to provide this service before the deceased fell at home between 11-12.1.2024.

At the time the deceased fell, she was wearing her wrist alarm but could not use it to summon help because it did not work.

None of the carers who attended on the deceased after 6.1.2024 ensured that steps were taken to replace the wrist alarm or report the matter to the local authority.

The last carer who attended on the deceased before she died, on the 11.1.2024, was not aware that the wrist alarm did not work as she had not read the care notes. No clear instruction was given to care workers about the extent to which they would be expected to read the care notes relating to service users.

None of the carers had been given any training, instruction, or guidance on the testing of wrist alarms to ensure they worked properly when attending upon service users.

There was no clear system identified between the company providing carers and the local authority, as to the duties and responsibilities of each in the reporting of faults with wrist alarms.