“There was a clear lack of understanding and basic knowledge of falls management by both…”

The coroner’s concerns

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— (1) There was a clear lack of understanding and basic knowledge of falls management by both trained nurses and support workers in circumstances in which it should have been obvious that Mr Preece sustained a head injury. The evidence clearly revealed that there was knowledge of a head injury following his seizure and fall. Even if that were not the case a head injury should have been suspected. (2) There was a clear lack of knowledge amongst all staff, both registered nurses. and support workers as to how to conduct neuro observations despite the evidence showing that guidance in the form of health board policy and also a “wall chart" was available to be consulted. (3) There was no forward planning for the continued observations of Mr Preece throughout the day on 9" September 2015 and as a result he was simply put to bed and not closely monitored as the circumstances required. (4) The evidence revealed that none of the registered nursing staff were trained either during their basic nurse training or subsequently upon employment within the health board, on how to conduct neuro observations and that together with a failure to appreciate an obvious head injury meant that not only observations conducted but that no medical assistance was sought for at least ten hours. (8) Evidence given at the inquest showed that the health board had considered the introduction of the NEWS scoring system (National Early Waring System) for the Mental Health Directorate but felt unable to introduce it as the mental health Unit did not sit within/alongside a district general hospital. The obvious concern being that against a background of poor training and poor management medically unwell mental health patients are at risk ‘ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and | believe you and your organisation have the power to take such action,

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, 2019-0019

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