“I heard that a key component of the policy to minimize the risk of falls is a thorough…”
Dated 22 Dec 2022, from the coroner for Gwent. 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 publishedReplies were due by 16 Feb 2023.
Organisations 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 dated22 Dec 2022
- Deadline16 Feb 2023
- Published on judiciary.uk4 Jan 2023
- Today23 Oct 2026
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Responses from each recipient
| Sent to | Response |
|---|---|
| Health Education and Improvement Wales | Response publishedPublished on judiciary.uk in January 2023. |
The coroner’s concerns
I heard that a key component of the policy to minimize the risk of falls is a thorough understanding of the multifactorial risk assessment process (MFRA) Whilst I was informed that all adult nurses were made aware of the risk of falls during their nurse training, they are not trained in the use of the MFRA. It is clear that newly qualified nurses rapidly assume responsibility for the care of a group of patients, often before they can undertake the MFRA training. The senior nurse who gave evidence and presented the internal investigation into the circumstances surrounding Mrs Phipps’ death, undertaken by Aneurin Bevan University Health Board, confirmed that it would be beneficial to the safety of patients if MFRA processes were taught to student nurses prior to qualification.
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, 2022-0413
- 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
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