“That insufficient cover is provided to allow 1:1 care to be given to patients that…”
Dated 21 Jan 2016, from the coroner for Inner West London. 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 17 Mar 2016. 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 dated21 Jan 2016
- Deadline17 Mar 2016
- Published on judiciary.uk21 Jan 2016
- Today23 Oct 2026
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Responses from each recipient
| Sent to | Response |
|---|---|
| St George's University Hospitals NHS Foundation TrustNamed in the report as “St George’s Hospital” | Deadline passedNo response published on judiciary.uk so far. The 56-day deadline was 17 Mar 2016. 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.
— (1) That insufficient cover is provided to allow 1:1 care to be given to patients that require it on this ward (Holdsworth) and likely others throughout the hospital, and as such patients are suffering preventable falls that may be causing fatal injury, or suffering other care deficiencies that may cause or contribute to death.
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, 2016-0016
- Added to Minute Book
- 8 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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