“The court heard evidence about Mr Keary falling over in a bathroom whilst a patient on…”

The coroner’s concerns

1. The court heard evidence about Mr Keary falling over in a bathroom whilst a patient on the OPAL Assessment Unit. On 28 September 2020, I issued a Prevention of Future Deaths Report to your predecessor following my investigation into the death of Mr William McKibbin who died at Trafford General Hospital on 20 August 2018 as a consequence of complications of a traumatic brain injury sustained in a fall there. In the Trust’s letter of response dated 23 November 2020 (pp. 7-8) the following is stated: “In addition, in response to the learning arising out of the review of Mr McKibbin’s care, a First Responder document has been developed and brought into use Trust-wide from September 2020, included as part of the updated Falls Investigation template. This document has been designed to support staff in investigating the immediate scene following an inpatient fall. Key considerations for completion of the First Responder document have been disseminated to staff using the ‘Feedback Friday’ campaign. This has included communicating that the First Responder document must be completed for all falls, even where patient harm is not suspected ” (emphasis added). In the light of evidence given by Wythenshawe’s current Director of Nursing, I am concerned that the First Responder document referred to above appears to have fallen out of use at the Trust. In view of the importance to patient safety of gathering the best available evidence as to the causes of falls and the precise circumstances in which they occur, I am concerned this creates an ongoing risk of future deaths. 2. I am concerned that when giving her evidence on 30 December 2025 before the inquest was adjourned to obtain further evidence, the co-ward manager of the OPAL Assessment Unit was not candid as to her understanding of the circumstances in which Mr Keary came to fall. Given the importance to the prevention of future deaths inherent in fostering a culture of openness and transparency in complex NHS organisations with a view to adverse incidents being quickly and fully understood, a lack of candour from those in management and / or leadership positions is a matter of particular concern. 11 COPIES AND PUBLICATION OF THIS REPORT I have a duty to send a copy of my report to every Interested Person who in my opinion should receive it. I also may send a copy of the report to any other person who I believe may find it useful or of interest. I can confirm I have sent the report to: [please do not use individual’s names, but instead roles/titles] Mr Keary’s family; The Trust’s legal department; The Nursing and Midwifery Council; and The Care Quality Commission. I also have a duty to send a copy of the report to the Chief Coroner. You may make representations to me, the coroner, about the publication of the contents of this report in line with Chief Coroner’s PFD Publication Policy (2026). Any representations will be sent to the Chief Coroner alongside the report. Please refer to box 4 above for additional information relating to the publication of reports and responses. 12 SIGNATURE

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, 2026-0377

Added to Minute Book

7 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