“Despite recommendations for falls prevention equipment being made by the Community Falls…”
Dated 10 Jul 2025, from the coroner for County Durham and Darlington. Sent to 4 organisations or people.
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 4 Sep 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 dated10 Jul 2025
- Deadline4 Sep 2025
- Published on judiciary.uk17 Jul 2025
- Today23 Oct 2026
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Responses from each recipient
| Sent to | Response |
|---|---|
| Williams and Spenceley Limited | Deadline passedNo response published on judiciary.uk so far. The 56-day deadline was 4 Sep 2025. A reply may have been sent and not yet published. |
| Howlish Hall Care Home | Response publishedPublished on judiciary.uk in July 2025. |
| Care Quality CommissionNamed in the report as “CQC” | Response publishedPublished on judiciary.uk in July 2025. |
| Durham County Council | Response publishedPublished on judiciary.uk in July 2025. |
The coroner’s concerns
– (1) Despite recommendations for falls prevention equipment being made by the Community Falls Service in August 2023, no falls prevention equipment was put in place by the time of the Deceased’s fall in October 2024 (2) Despite the social worker expressing concern about the lack of falls prevention equipment on 27 September 2024, no falls equipment was put in place prior to the Deceased’s fall on 4 October 2024. (3) Information about the Community Falls Service recommendations was not passed on to the family, or to social services. (4) On 5 August 2024 (following a fall, but before the more significant fall on 4 October 2024), the Deceased’s family were told by the Deputy Manager of Howlish Hall that the owner of Howlish Hall “probably wouldn’t want to pay for a sensor mat”. (5) I received evidence that, subsequent to the Deceased’s death, there had been a reluctance on the part of (who was believed to be the owner of Howlish Hall Care Home) to provide adequate resources for falls prevention equipment. (6) Despite it being recognised that the Deceased lacked mental capacity to make decisions about where she lived and was unable to keep herself safe, it appears that the home did not make any application for a DoLS assessment for the Deceased. Indeed I received evidence that when a new home manager was appointed at Howlish Hall in January 2025 none of the residents were subject to a DoLS, despite a large number of the residents lacking mental capacity.
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, 2025-0354
- 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
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