“Derriford Hospital in Plymouth is the main acute hospital site managed by UHP NHS”

The coroner’s concerns

Derriford Hospital in Plymouth is the main acute hospital site managed by UHP NHS. UHP NHS carried out a Root Cause Analysis (RCA) investigation in respect of the circumstances which led to Mary Pomeroy being pushed to the ground by a fellow patient on a ward at Derriford Hospital, Plymouth and her death thereafter. This investigation culminated in a written investigation report which was given executive sign off on 14 July 2022, by the SI panel chair and chief nurse of UHP NHS. The main body of the investigation report concluded that the incident which led to Mary Pomeroy being pushed to the ground by a fellow patient was ‘a rare and devastating accident for which could not have been foreseen’. The summary of the SI Panel Meeting Review, chaired by the Chief Nurse on 4 July 2022, stated that ‘overall it was considered that [the patient who pushed Mary Pomeroy] was managed appropriately during his admission to UHP NHS and concluded that this was a deeply unfortunate accident, but not one that could have been anticipated and therefore prevented by staff.’ The inquest heard evidence that the patient who pushed Mary Pomeroy to the ground on 3 March 2022 had done almost exactly the same thing to another patient on the ward only two days previously, on 1 March 2022 – this incident was discussed in the main body of the RCA investigation report, but not referred to at all in the SI Panel Meeting Review summary. The inquest also heard evidence that the patient who pushed Mary Pomeroy had been involved in a number of incidents where he had used physical force on staff members on the ward in February 2022. At the inquest, the author of UHP NHS’s investigation report (who was the Matron of the relevant ward) accepted, in evidence, that the patient who pushed Mary Pomeroy should, on 3 March 2022, have been subject to enhanced observations of care – this was on the basis that previous assessments in November 2021 and January 2022 had shown that this was required for him owing to his psychiatric and behavioural presentation (which had become more concerning by the end of February/beginning of March 2022) and also because of very recent and specific concerns regarding his behaviour which should have been obvious to ward staff following the incident on 1 March 2022. The Matron accepted, in evidence, that had enhanced observation and care been in place for the patient (which could have taken a number of forms following assessment, depending on what would have been most clinically and therapeutically appropriate at the time) then he should have been prevented from being in a position where he was able to push Mary Pomeroy to the ground on 3 March 2022. The Matron accepted, in evidence, that UHP NHS’s RCA report had been incorrect to conclude that the type of incident that occurred on 3 March 2022 could not have been foreseen. The Deputy Chief Nurse of UHP NHS accepted, in evidence, that the SI Panel Meeting should have interrogated the relevant facts and chronology more. The inquest determined that the incident on the ward on 3 March 2022 was foreseeable, based on the concerns about the patient’s behaviour, the likely triggers for him becoming distressed and aggressive and the almost identical incident that had occurred on 1 March 2022. The inquest also determined that the lack of assessment and management of this patient’s behaviour and needs materially contributed to the incident which led to Mary Pomeroy suffering injuries and led to her death. It is unfortunately clear, when comparing the evidence heard at the inquest with the findings of UHP NHS’s RCA report, that there was inadequate analysis of this serious incident by UHP NHS, with concerning circumstances surrounding the care provided not being identified – therefore appropriate recommendations to inform future care provision were not given consideration as part of the RCA investigation/report. If UHP NHS do not identify concerning matters when carrying out internal investigations and do not take steps to try and learn from serious incidents when they occur, then there is an obvious, significant and continuing risk of future deaths occurring arising out of healthcare provision provided.

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, 2025-0166

Added to Minute Book

8 Oct 2026

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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