“Following Mr Horrocks death an investigation was undertaken by the hospital, the report…”

The coroner’s concerns

Following Mr Horrocks death an investigation was undertaken by the hospital, the report in respect thereof being provided to the court late on the afternoon 22 October 2025. The hospital investigation identified inter alia that observations were not completed on the ward overnight on 14 March 2025 in accordance with escalation guidance with no documented reason. Whilst the evidence did not identify Mr Horrocks "baseline" NEWS score, evidence at the inquest hearing from consultants involved in Mr Horrocks care identified a NEWS score of 5 required further observations and possible escalation. Further, that it was likely that there was an ongoing deterioration from late on 14 march 2025 into 15 March 2025 which was only appreciated when further observations were undertaken shortly before midday on 15 March 2025 identifying an increase in the NEWS score to 12. The evidence indicated however that in Mr Horrocks case, even if his deterioration had been identified sooner, on a balance of probabilities, it would not have avoided his death when it occurred. The hospital investigation also identified that during this period the ward bed capacity had been increased from 27 to 33 beds owing to winter pressures with no corresponding change to the nursing establishment on the ward. Further, during this period there were gaps in the existing nursing establishment on the ward. Whilst the hospital investigation had identified these matters, there were no recommendations that these were issues for wider learning or how, if at all, these issues were to be addressed.

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, 2025-0545

Added to Minute Book

8 Oct 2026

Reuse

We show short extracts and link to the original. We don’t host the full report.

Something wrong, such as a date or who it was sent to? Report a mistake

Is this report about someone close to you? You can ask us to remove names from our pages.

Contains public sector information licensed under the Open Government Licence v3.0. Source: Courts and Tribunals Judiciary, judiciary.uk. Open Government Licence v3.0