“(brief summary of matters of concern) 1”

The coroner’s concerns

(brief summary of matters of concern) 1. Falls risk assessments. Only 2 falls risk assessments were carried out after Mr Tarrant arrived at the hospital. Both falls risk assessments used the Hester Davis scoring system but both had carried out based on incorrect data. The falls risk assessments both resulted in a low-risk outcome which was not correct. Mr Tarrant should have been graded as a moderate risk even prior to his fall. Some of the data entered into the risk assessment tool was objectively wrong. For example in the risk assessment carried out hours after his fall it stated that he had not fallen before. I heard that the Trust did not have a way of assessing and auditing the accuracy of these risk assessments. Whilst I found that the errors in this inquest did not contribute to Mr Tarrant’s death incorrect risk assessments can lead to inadequate falls mitigation measures being put in place and incorrect information being provided to staff. 2. Anti coagulation risk awareness The doctor who reviewed the CT results and neurosurgery advice after Mr Tarrant fell did not appreciate the urgency of the situation. I found in this inquest that due to timing issues this was not likely to have affected the outcome for Mr Tarrant. I heard from the consultant witness that the risks of anticoagulation are poorly understood. The post falls proforma was reviewed in court and, whilst it asked whether the patient was on anticoagulation medication, it did not provide a prompt about this during the post fall medical planning section. This led to a concern that the importance of considering administering an anticoagulation reversal medication and the urgency of such a need may be underappreciated.

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, 2026-0199

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