“(brief summary of matters of concern) During the course of the inquest, evidence was…”

The coroner’s concerns

(brief summary of matters of concern) During the course of the inquest, evidence was heard from Ward Manager the Ward Manager from Ward 35. She confirmed that it was unlikely that the deceased had been provided with his allocated walking frame on admission to Ward 35; the clinical notes did not refer to him having been provided with that mobility aid. The evidence of was that even if a walking frame had been allocated to a patient at an earlier stage in the hospital admission process, that walking frame would not automatically follow the patient on their onward journey onto other wards or other areas of the hospital. The evidence was that a reassessment would be undertaken on admission to a new ward and a decision would then be taken in relation to the provision of such mobility aids. In this case, it is likely that the deceased had been on Ward 35 for around 2 hours and 40 minutes and he still had not been provided with an allocated walking frame for his own use. Whilst it cannot be said that this lack of a walking frame contributed to the deceased’s fall, given that he likely used a frame belonging to someone else, it is a matter of concern that a patient could be admitted onto a ward without being provided with the mobility aids that they had been previously assessed by the hospital as requiring and which had already been allocated to that patient at an earlier stage in the hospital admission process. I am therefore concerned about the consistency of the provision of such mobility aids during the course of a patient’s admission. I am concerned that this creates a risk of future deaths to other patients in circumstances where they are transferred onto wards without them having the mobility aids which they have been assessed as requiring, and with which they have already been provided at an earlier stage whilst in hospital.

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, 2026-0144

Added to Minute Book

8 Oct 2026

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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