“The falls risk assessment was not completed within the first 24 hours of admission to the…”
Dated 28 Aug 2025, from the coroner for Somerset. 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 23 Oct 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 dated28 Aug 2025
- Deadline23 Oct 2025
- Published on judiciary.uk2 Sep 2025
- Today23 Oct 2026
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Responses from each recipient
| Sent to | Response |
|---|---|
| Somerset NHS Foundation Trust | Response publishedPublished on judiciary.uk in September 2025. |
The coroner’s concerns
– 1. The falls risk assessment was not completed within the first 24 hours of admission to the ward. 2. Had it been completed, the risk assessment would have involved obtaining information from the nursing home as Mr Price was unable to communicate. 3. A risk assessment would have identified Mr Price’s specific risk of falling out of bed. 4. The lack of a risk assessment meant that mitigation measures were not in place. 5. The lack of mitigation measures made a more than minimal contribution to the extent of Mr Price’s injuries and therefore to his death. 6. No subsequent action has been taken by the ward to address the gaps in the falls risk assessment and management process when patients are admitted from care homes.
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, 2025-0440
- 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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