“The deceased was assessed as a level 3 falls risk meaning she was to be kept under line…”
Dated 18 Mar 2025, from the coroner for Northumberland. Sent to 1 organisation or person.
A coroner wrote this report after an inquest, to warn the organisations below about a risk of further deaths.
The 56-day response deadline
All responses publishedReplies were due by 13 May 2025.
Organisations that receive a report must reply to the coroner within 56 days, saying what they will do or why they will do nothing. We show whether a response is published on judiciary.uk; a reply may have been sent and not yet published.
- Report dated18 Mar 2025
- Deadline13 May 2025
- Published on judiciary.uk26 Mar 2025
- Today23 Oct 2026
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Responses from each recipient
| Sent to | Response |
|---|---|
| Northumbria Healthcare NHS Foundation TrustNamed in the report as “NORTHUMBRIA HEALTHCARE NHS FOUNDATION TRUST” | Response publishedPublished on judiciary.uk in March 2025. |
Some responses were published as scans, so their text was read automatically. Check the wording against the original before you quote it.
The coroner’s concerns
(1) The deceased was assessed as a level 3 falls risk meaning she was to be kept under line of sight in case of falling. Witness statements served in advance of the inquest stated the fall was witnessed. It was however eventually accepted in evidence that the fall was in fact unwitnessed. The precise 5 circumstances of the fall could not be determined. All of the investigations undertaken by the Trust relied upon the incorrect understanding that the fall was witnessed and observations were in line with Trust falls policy, when they were not. (2) The inquest heard that it is practice within the Trust that a Nursing Assistant is to be located centrally in the corridor on ward 9 to oversee patients assessed as at risk of falling and for the patients to be within staff's peripheral vision. The inquest heard that on 24 April 2024 8 patients were assessed as level 3 falls risk and 1 patient was assessed as level 4 falls risk. I am concerned as to the number of patients at risk of falls being observed in this way. I am further concerned that there is a misunderstanding of what is meant by peripheral vision and what constitutes a witnessed or unwitnessed fall. (3) I am concerned there is not greater scrutiny of witness accounts as part of the Trust's investigation process in particular given the concerns raised by the deceased's family early in the investigation and the other witness accounts to provide earlier learning to prevent future events.
An extract. Read the full report, including the circumstances of the death, on the Courts and Tribunals Judiciary website.
- Source
- judiciary.uk, Prevention of Future Deaths reports, 2025-0149
- Added to Minute Book
- 8 Oct 2026
- Reuse
- We show short extracts and link to the original. We don’t host the full report.
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Contains public sector information licensed under the Open Government Licence v3.0. Source: Courts and Tribunals Judiciary, judiciary.uk. Open Government Licence v3.0
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