“The inquest was advised that a Falls Panel had been convened to determine, in part…”
Dated 20 Mar 2024, 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 15 May 2024.
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 dated20 Mar 2024
- Deadline15 May 2024
- Published on judiciary.uk21 Mar 2024
- Today23 Oct 2026
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Responses from each recipient
| Sent to | Response |
|---|---|
| Aneurin Bevan University Health Board | Response publishedPublished on judiciary.uk in March 2024. |
The coroner’s concerns
The inquest was advised that a Falls Panel had been convened to determine, in part, whether action could have been taken to prevent a fall which had occurred on 23/04/23. I received no evidence that there had been any investigation into the other falls including, importantly, the fall on 01/05/23 that contributed to Mr Edwards’ death. The court regularly hears that investigations into the circumstances of in-patient falls is central to minimising the risk going forward. It is of concern that no such investigation was undertaken at this time. 6 Additionally, as there was no investigation, the court was not reassured as to how deaths in similar circumstances might be prevented in the future.
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, 2024-0153
- 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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