“Between January 2017 and April 2017 five deaths occurred on Cambridge Wards at William…”

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 King a falls risk assessment and precautions to minimise the risk of falls was not properly documented; interventions were not recorded and no referrals were made to either the falls team or physiotherapy. A bed rails risk assessment was completed which recorded that bed rails were not recommended but were in use at the time of the fall. (3) When Mr King was transferred to Cambridge ward from the clinical decision unit the receiving nurse recognised that Mr King should have been nursed in an observable bed with a crash mat and as neither were available on the ward, escalated the matter to the site coordinator. There was no evidence that these concerns were ever addressed by the site coordinator or followed up by nursing staff (4) A review of the falls risk assessment and bed rails assessment was recorded, however the fact that interventions were required to prevent the risk of falls was either not recognised or not implemented. (5) Falls risk was not addressed at handover

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, 2017-0414

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