“Oral evidence given at the inquest revealed that in the opinion of a senior staff member…”
Dated 28 Jul 2026, from the coroner for Worcestershire. 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 publishedOrganisations 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 dated28 Jul 2026
- Deadline22 Sep 2026
- Published on judiciary.uk28 Sep 2026
- Today24 Oct 2026
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Responses from each recipient
| Sent to | Response |
|---|---|
| Worcestershire Acute Hospitals NHS Trust | Response publishedPublished on judiciary.uk in September 2026. |
The coroner’s concerns
Oral evidence given at the inquest revealed that in the opinion of a senior staff member, there is insufficient awareness of the requirements of the ‘Stay in the bay’ falls prevention initiative and Level 3 observations, which in their opinion, is a result of insufficient training on the subject. 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: Daughter of the deceased 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 HM Assistant Coroner for Worcestershire
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, 2026-0381
- Added to Minute Book
- 7 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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