“The failure of nurses on the ward to instigate an adequate falls risk assessment of Mrs…”
Dated 25 Feb 2026, from the coroner for East London. Sent to 2 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
All responses publishedReplies were due by 22 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 dated25 Feb 2026
- Deadline22 Apr 2026
- Published on judiciary.uk3 Mar 2026
- Today23 Oct 2026
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Responses from each recipient
| Sent to | Response |
|---|---|
| Barts Health NHS Trust | Response publishedPublished on judiciary.uk in March 2026. |
| Department of Health and Social CareNamed in the report as “Department for Health and Social Care” | Response publishedPublished on judiciary.uk in March 2026. |
The coroner’s concerns
- 1. The failure of nurses on the ward to instigate an adequate falls risk assessment of Mrs Patel. 2. The failure of nursing staff on the ward to produce a meaningful care-plan for Mrs Patel’s mobility. 3. The failure of Trust staff to note a fall on 23rd June 2025 and reassess risk of falls. 4. The failure of nursing staff on the ward to monitor and supervise Mrs Patel on the afternoon of 29th June 2025. 5. The failure of Trust staff to adequately assess the likelihood of a traumatic intra-cranial bleed following the fall on 29th June 2025. 6. The failure of the duty doctor to act decisively and refer Mrs Patel for an urgent CT Head scan on 29th June 2025. 7. The failure of the duty doctor to review Mrs Patel’s warfarin prescription after the fall. 8. The failure of ward staff on the ward round on 30th June 2025 to read the clinical records from the previous day to alert them to Mrs Patel’s fall on 29th June 2025.
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, 2026-0116
- 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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