“(brief summary of matters of concern) The Court heard evidence that risk assessments were…”

The coroner’s concerns

(brief summary of matters of concern) The Court heard evidence that risk assessments were to be carried out regularly on patients in relation to their falls risk. This is particularly important in circumstances where a patient was being transferred between wards/units within the hospital and where the risk to the patient may change due to the change in environment. Mr. BURKE was such a risk from falling whilst on the ward and therefore arrangements were required to be put in place to manage this risk, informed by a risk assessment. He had been admitted to Ipswich Hospital on 26th January 2023 following an unwitnessed fall at rehabilitation centre where he had been discharged to from Ipswich Hospital the previous day; 25th January 2023. Mr. BURKE was moved to a new ward on the 30th January 2023 following his admission, assessment and initial treatment. He was not risk assessed when transferred to the ward and the outstanding task to carry out the risk assessment had not been completed by the end of the shift during which he had been transferred onto the ward. This requirement was not handed over to the on-coming shift and a falls risk assessment had not been completed at the time Mr. BURKE sustained a fall on the ward. I am concerned that Ipswich Hospital has inadequate arrangements in place to both highlight circumstances where the requirement for risk assessments have not been completed and in the arrangements for the handover of tasks (particularly falls assessments) between shifts. I am further concerned that the failure to have adequate arrangements in place to address this raises a risk of future deaths which I am under a duty to bring to your attention.

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, 2024-0302

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