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Mrs Stillwell died after a second fall on that day.
Mr Irvine said: Mrs Stillwell was at high risk of falls caused by a combination of factors; Mrs Stillwell s frailty, her dementia which limited her perception of risk, whilst at the same time made her forget her mobility restrictions, and her independent and assertive nature.
One-to-one care would have been the only way in which the particular risk presented by Mrs Stillwell to herself could have been mitigated.
He wrote that action should be taken to prevent future deaths and sent the report to Havering CCG and the Department of Health and Social Care. ....

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