“There are several areas of concern around failures in documentation and failures to…”
Dated 17 Jun 2025, from the coroner for South Yorkshire East. 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 12 Aug 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 dated17 Jun 2025
- Deadline12 Aug 2025
- Published on judiciary.uk30 Jun 2025
- Today23 Oct 2026
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Responses from each recipient
| Sent to | Response |
|---|---|
| The Rotherham NHS Foundation TrustNamed in the report as “Rotherham NHS Foundation Trust” | Response publishedPublished on judiciary.uk in June 2025. |
The coroner’s concerns
– There are several areas of concern around failures in documentation and failures to follow Trust policy, namely: 1. Lying and standing Blood Pressure was not recorded on admission. 2. There was no documentation of any falls prevention measures at the time of the first falls assessment. 3. There is no evidence of falls prevention measures being put in place following the first falls assessment. 4. There was no falls assessment done at the time of transfer to ward B4. There should have been a falls assessment within six hours of transfer but that did not happen. The assessment took place some 23 hours after admission to the ward, by which time Mrs Gambles had already fallen. 5. Following the in-patient fall there was a delay of over 5 hours before a medical review took place. The note recording the request for medical review is not timed. 6. There was no discussion with Mrs Gambles' family explaining the findings of the CT scan and they were not told about the bleed on the brain. 7. No Datix report was done following the in-patient fall leading to a delay in investigation. 8. The in-patient fall is not mentioned on the Discharge letter. I am concerned that these failures suggest a lack of awareness of, and lack of compliance with, the Trust’s processes on falls assessment and record keeping. 6. ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you 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 the 12th August 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, 2025-0303
- 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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