“Staffing Levels Aneurin Bevan University Health Board undertook an internal investigation…”

The coroner’s concerns

1. Staffing Levels Aneurin Bevan University Health Board undertook an internal investigation which was presented at the inquest by confirmed that Mrs Robinson had not been correctly assessed and warranted a higher level of supervision to minimise the risk of her falling. Whilst the documentation was not completed, two nurses gave evidence and I was reassured that they both understood that Mrs Robinson was at high risk of falls and were monitoring her as closely as possible with the staffing complement available. I was informed that on the ward at YYF there were usually 3 members of nursing staff to care for 15 patients. Mrs Robinson was in a cohorted group which meant that 1 member of staff was assigned to observe a group of 4 patients at all times. This left 2 nurses for the remaining 11 patients. The nurses who gave evidence both told me that they rarely managed to get their full breaks (40 minutes in a 12 hour shift) and were constantly in a position where they did not feel they could deliver a safe standard of care to the patients. Mrs Rowlands confirmed that staffing levels were not considered during the investigation and it was further confirmed that these apparently low staffing levels still exist. 2. Serious Concerns report findings At the inquest, Mrs Rowlands described the omissions in the falls risk assessment process and the steps that are now being taken to ensure that staff complete the documentation properly. It is my understanding that the internal investigation is an essential component of organisational learning to improve the quality of care to patients and also prevent future deaths. Mrs Rowlands informed me that falls were the greatest risk posed to patients by the Health Board. I was therefore concerned to hear that neither of the nursing staff who gave evidence had seen the findings of the internal investigation some 1 years and 4 months since Mrs Robinson's death.

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, 2021-0072

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