“Evidence emerged during the inquest that Mrs Farmer had a risk of a falling (moderate to…”
Dated 24 Nov 2016, from the coroner for Black Country. 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 dated24 Nov 2016
- Deadline19 Jan 2017
- Published on judiciary.uk19 Feb 2017
- Today27 Oct 2026
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Responses from each recipient
| Sent to | Response |
|---|---|
| Sandwell and West Birmingham Hospitals NHS TrustNamed in the report as “Sandwell and West Birmingham Hospital NHS Trust” | Response publishedPublished on judiciary.uk in February 2017. |
The coroner’s concerns
– 1. Evidence emerged during the inquest that Mrs Farmer had a risk of a falling (moderate to high risk). There was no evidence that a falls risk assessment had been completed. 2. Given the risks of falls, there was no clear justification for moving her from a monitored bay to an unmonitored bay. 3. After the fall, only one set of neurological observations were performed before her discharge. 4. In addition no CT Head scan was performed despite evidence of significant bruising to her face and head.
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, 2016-0420
- 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
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