“Notwithstanding the fact that the document had passed through the Trust’s quality…”

The coroner’s concerns

– 1. Notwithstanding the fact that the document had passed through the Trust’s quality assurance process, it is a matter of concern that the Root Cause Analysis investigation into the circumstances of Mr Holmes’s fall contained a number of basic and obvious errors. Prompt, rigorous and effective investigations of clinical incidents are essential to deriving learning and improving patient safety, thereby reducing the risk of future deaths; 2. The formal learning derived from the Trust’s investigation (in the form of an Action Plan to the Root Cause Analysis) does not appear to take into account the breadth of issues raised by the case and which were apparent to the Trust from complaints correspondence and statements obtained from staff in advance of the inquest. As such, the Trust does not appear to have taken the opportunity to formally examine and critically analyse key issues such as:   the adequacy of existing processes designed to ensure patient call-bells are working at all times; and why a delay has occurred in obtaining advice from a specialist hospital in the present case and whether the processes by which such advice is obtained are fit for purpose. 3. Connected with the above, the Trust does not appear to have revisited the grading of “moderate” harm originally assigned to Mr Holmes’s fall on the Acute Medical Unit notwithstanding his death being reported to the Coroner on the basis there was reason to suspect it contributed to his death. The court heard evidence to the effect that this grading informs the nature and extent of investigation which arises from a patient safety incident (thus impacting upon the learning which can be derived from such an incident).

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, 2022-0188

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