“(brief summary of matters of concern) The Occupational Therapist involved in the…”
Dated 23 Feb 2026, from the coroner for County Durham and Darlington. 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 20 Apr 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 dated23 Feb 2026
- Deadline20 Apr 2026
- Published on judiciary.uk2 Mar 2026
- Today23 Oct 2026
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Responses from each recipient
| Sent to | Response |
|---|---|
| County Durham and Darlington NHS Foundation TrustNamed in the report as “County Durham & Darlington NHS Foundation Trust” | Response publishedPublished on judiciary.uk in March 2026. |
The coroner’s concerns
(brief summary of matters of concern) The Occupational Therapist involved in the deceased's discharge on 1 May 2025 gave evidence that for someone to be assessed as safe to use the stairs on their own, it was not Regulation 28 – After Inquest Document Template Updated 30/07/2021 sufficient for them to have managed to complete a set of stairs without assistance on one occasion; it was necessary for the person to demonstrate that they could consistently complete the stairs without assistance. The Occupational Therapist stated that the two successful attempts in the Care Home seemed to be enough to achieve consistency and indicated that if similar circumstances arose today the patient would still be discharged home at the end of the six-week rehabilitation period. I found as a fact that prior to the deceased's discharge on 1 May 2025 the deceased had not demonstrated that she was able to consistently complete a flight of stairs without assistance. I am concerned by the evidence that if similar circumstances arose today the patient would still be discharged. I am concerned that there may be occasions in the future that patients will be discharged before they are able to consistently complete a flight of stairs and that, as a result, a death may occur.
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, 2026-0112
- 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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