“{n evidence the Matron was asked whether it might be preferable for the falls risk…”
Dated 3 Mar 2015, from the coroner for County Durham. 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
Deadline passedReplies were due by 28 Apr 2015. A reply may have been sent and not yet published.
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.
- Report dated3 Mar 2015
- Deadline28 Apr 2015
- Published on judiciary.uk3 Mar 2015
- Today23 Oct 2026
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Responses from each recipient
| Sent to | Response |
|---|---|
| County Durham and Darlington NHS Foundation Trust | Deadline passedNo response published on judiciary.uk so far. The 56-day deadline was 28 Apr 2015. A reply may have been sent and not yet published. |
The coroner’s concerns
This report was published as a scan, so its text was read automatically. Check the wording against the original before you quote it.
— {n evidence the Matron was asked whether it might be preferable for the falls risk assessment form to give a presumption that certain classes of patients (for example stroke patients) were at increased risk of falls and should be considered as such unless there were good reasons to the contrary. It was her view that this would not be good practice as each and every patient should be assessed on an individual basis. Whilst | that is a laudable outlook it was put to her that if there had been such a presumption then the misclassification by the original staff nurse and by the student nurse might have_| been avoided and this could lead either in this case or in other cases to a potentially different outcome. The matron’s view was that freedom of assessment was nevertheless best practice. | indicated my concern over this issue as to whether there should be a presumption in certain cases of an increased risk of falls and that consideration of this issue would be useful. |; ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and | believe your organisation have the power to take such action.
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, 2015-0076
- Added to Minute Book
- 8 Oct 2026
- Reuse
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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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