“Whether sufficient consideration is given to falls prevention measures on the surgical…”
Dated 18 Apr 2019, from the coroner for Gloucestershire. 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 dated18 Apr 2019
- Deadline13 Jun 2019
- Published on judiciary.uk14 Jun 2019
- Today23 Oct 2026
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Responses from each recipient
| Sent to | Response |
|---|---|
| Gloucestershire Hospitals NHS Foundation TrustNamed in the report as “Gloucestershire Hospitals NHS Trust” | Response publishedPublished on judiciary.uk in June 2019. |
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. Whether sufficient consideration is given to falls prevention measures on the surgical ward, 2. Whether there is sufficient understanding of the post falis protocol that must be followed on the surgical ward, 3. Whether there is sufficient understanding that a medical review of a patient post fall must include review of their current medications, 4. When a patient is transferred between wards, whether there is sufficient handover of safety information pertaining to a patient.
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
- 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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