“The Trust’s failure to prevent a predictable and therefore avoidable fall which resulted…”
Dated 25 Jul 2024, from the coroner for East London. Sent to 2 organisations or people.
A coroner wrote this report after an inquest, to warn the organisations below about a risk of further deaths.
The 56-day response deadline
Deadline passedReplies were due by 19 Sep 2024. A reply may have been sent and not yet published.
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.
- Report dated25 Jul 2024
- Deadline19 Sep 2024
- Published on judiciary.uk1 Aug 2024
- Today23 Oct 2026
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Responses from each recipient
| Sent to | Response |
|---|---|
| Barts Health NHS TrustNamed in the report as “Barts Health Foundation Trust” | Deadline passedNo response published on judiciary.uk so far. The 56-day deadline was 19 Sep 2024. A reply may have been sent and not yet published. |
| Department of Health and Social Care | Response publishedPublished on judiciary.uk in August 2024. |
The coroner’s concerns
– 1. The Trust’s failure to prevent a predictable and therefore avoidable fall which resulted in death. 2. Despite this incident activating the PSIRF process which resulted in the completion of an After Action Review (“AAR”), the Trust did not identify any suboptimal aspects to Mrs Holder’s care. Accordingly, I have a concern regarding the failure of the Trust’s governance systems to; a. Identify and reflect upon failings in care, b. Consequently, the failure of the trust to act in a way to remediate the factors that contributed to Mrs Holder’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, 2024-0403
- 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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