“| was told in evidence that at the time of the accident the ward was being covered by two…”
Dated 28 Mar 2018, from the coroner for Avon. 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 16 Jun 2018, after the 56 days for replies had ended (23 May 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 dated28 Mar 2018
- Deadline23 May 2018
- Published on judiciary.uk16 Jun 2018
- Today23 Oct 2026
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Responses from each recipient
| Sent to | Response |
|---|---|
| Bristol NHS Foundation TrustNamed in the report as “Bristol NHS Trust” | Report put online after its 56 daysNo response published on judiciary.uk. judiciary.uk put this report online on 16 Jun 2018, after the 56 days for replies had ended (23 May 2018). These dates can’t tell us whether a reply was due before it went online. |
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) | was told in evidence that at the time of the accident the ward was being covered by two nurses and two nursing assistants (ie, by 4 staff), but that two of those staff had taken their 1-hour break at the same time; effectively leaving the ward with very little cover. The fall had then occurred when a nursing assistant left the deceased’s bay to help another member of staff to change a bed (leaving him entirely unsupervised). (2) While | would be concerned in any event that staff had taken their breaks at the same time — given the effect that that would inevitably have on the remaining nurses’ ability to cope with the patients on the ward —| was even more concerned when the nursing assistant who gave live evidence at the inquest told me that this was a practice which was still taking place; despite it having been highlighted and criticised in the serious untoward incident report.
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, 2018-0089
- 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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