“(brief summary of matters of concern) The Inquest heard evidence about the Trust’s use of…”
Dated 6 Nov 2025, from the coroner for Cambridgeshire and Peterborough. 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 1 Jan 2026.
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 dated6 Nov 2025
- Deadline1 Jan 2026
- Published on judiciary.uk11 Nov 2025
- Today23 Oct 2026
Watch this report
We’ll email you when a response is published on judiciary.uk, or when the 56 days to reply end with none published there yet. Free, and you can stop with one click.
Responses from each recipient
| Sent to | Response |
|---|---|
| North West Anglia NHS Foundation TrustNamed in the report as “Chief Medical Officer for North West Anglia Foundation Trust” | Response publishedPublished on judiciary.uk in November 2025. |
The coroner’s concerns
(brief summary of matters of concern) The Inquest heard evidence about the Trust’s use of the ‘Close Observation Risk Assessment’ (p1903 Medical Records Bundle). This requires scores to be attributed to several factors including ‘inpatient falls during this admission’ and ‘previous falls’. The overlap between these two factors and what they actually refer to is unclear and confusing. This creates a risk that the overall score may be calculated incorrectly resulting in insufficient levels of observation, increased risk of falls and death.
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, 2025-0563
- 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
Ask about this report
AISummaries and questions, with page references. Pro and above.
Sign in to use