“the patient was identified as at high risk of a fall (2) he was deemed to be severely…”
Dated 3 Jun 2025, from the coroner for South London. 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
Deadline passedReplies were due by 29 Jul 2025. A reply may have been sent and not yet published.
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.
- Report dated3 Jun 2025
- Deadline29 Jul 2025
- Published on judiciary.uk17 Jun 2025
- Today23 Oct 2026
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Responses from each recipient
| Sent to | Response |
|---|---|
| Epsom and St Helier University Hospitals NHS TrustNamed in the report as “Epsom and St. Helier University Hospitals NHS Trust” | Deadline passedNo response published on judiciary.uk so far. The 56-day deadline was 29 Jul 2025. A reply may have been sent and not yet published. |
The coroner’s concerns
(1) the patient was identified as at high risk of a fall (2) he was deemed to be severely frail (and hence at corresponding risk, if a fall were to occur) (3) there were no crash mats at the side of his bed (4) it was known that the patient had a propensity to push staff when being changed (5) the bed-rail was not up when the patient was attended by a HCA acting alone (6) that HCA was unable, on his own, to hold on to the patient, in order to prevent him from falling out of bed (7) the patient should have had the assistance of two members of staff, and not just one, when being prepared to be washed and changed All of these matters are recorded in the Trust's own Datix report.
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, 2025-0282
- 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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