“There was a lack of evidence suggested appropriate falls risk assessments had been…”
Dated 26 May 2025, from the coroner for Cumbria. 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 21 Jul 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 dated26 May 2025
- Deadline21 Jul 2025
- Published on judiciary.uk17 Jun 2025
- Today23 Oct 2026
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Responses from each recipient
| Sent to | Response |
|---|---|
| North Cumbria Integrated Care NHS Foundation Trust | Response publishedPublished on judiciary.uk in June 2025. |
The coroner’s concerns
– (1) There was a lack of evidence suggested appropriate falls risk assessments had been undertaken and a failure to report falls / collapses on the ward . (2) There was a lack of documentation about the use of cot sides and the placement of the call bell within Mrs Hill's reach . (3) There was a lack of frequent recorded observations necessitated by Mrs Hill's deteriorating condition. (4) Mrs Hill was placed in a side room where she was not easily observed without consideration given for the need for additional monitoring which led to her being left alone for extended periods of time. (5) I was advised that the ward was understaffed and under pressure .I was told that despite this being appropriately escalated nurses were caring for 10 patients when the expected allocation would be 6 patients for each nurse on duty .No further help was provided to the ward following escalation . The evidence presented to me was that this was not an unusual situation on the ward . 6) ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you North Cumbria Integrated Care NHS Trust have the power to take such action. 7) YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 22 July 2025. I, the coroner, may extend the period.
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, 2025-0280
- Added to Minute Book
- 8 Oct 2026
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- 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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