“Between January 2017 and April 2017 five deaths occurred on Cambridge Wards at William…”
Dated 20 Nov 2017, from the coroner for Central and South East Kent. 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
Report put online after its 56 daysOrganisations 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.
judiciary.uk put this report online on 26 Feb 2018, after the 56 days for replies had ended (15 Jan 2018). These dates can’t tell us whether a reply was due before it went online. A reply may have been sent and not yet published.
- Report dated20 Nov 2017
- Deadline15 Jan 2018
- Published on judiciary.uk26 Feb 2018
- Today23 Oct 2026
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Responses from each recipient
| Sent to | Response |
|---|---|
| East Kent Hospitals University NHS Foundation TrustNamed in the report as “East Kent Hospitals University NHS Trust” | Report put online after its 56 daysNo response published on judiciary.uk. judiciary.uk put this report online on 26 Feb 2018, after the 56 days for replies had ended (15 Jan 2018). These dates can’t tell us whether a reply was due before it went online. |
The coroner’s concerns
– (1) Between January 2017 and April 2017 five deaths occurred on Cambridge Wards at William Harvey Hospital. Common to each was the fact that the death was caused as a result of a fall on the ward in circumstances where falls risk assessments were either inadequate, incomplete, not reviewed or not enforced. Inquests in respect of each the deaths have been held, the last in November 2017. The Trust was given an opportunity following the earlier inquests to provide evidence of changes to practice following the deaths. It is recognised that at the time of hearing the inquests much work has already been done to address these issues but that work is ongoing and parts of that work have not yet been implemented/were in the process of being implemented. It is for this reason that Regulation 28 reports arise from three of the deaths. (2) In respect of Mr Honour the falls risk assessment completed on admission was at best perfunctory, as were subsequent reviews which did not rectify earlier errors or recognise the need for precautionary measures to be taken when Mr. Honour should have been nursed in an observable bed with a falls alert and hip protectors in light of the risks posed. (3) The bedrail risk assessment was difficult to interpret in light of the falls risk assessment, bed rails were utilised when they should not have been. (4) The falls risk assessment was not updated post fall and no protective measures were put in place.
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, 2017-0413
- 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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