“In view of Ms de Ceita’s known risk of falling, staff at the hospital decided to put in…”
Dated 31 Jul 2024, from the coroner for North London. 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 25 Sep 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 dated31 Jul 2024
- Deadline25 Sep 2024
- Published on judiciary.uk15 Aug 2024
- Today27 Oct 2026
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Responses from each recipient
| Sent to | Response |
|---|---|
| North Middlesex University Hospital NHS Trust | Response publishedPublished on judiciary.uk in August 2024. |
The coroner’s concerns
– In view of Ms de Ceita’s known risk of falling, staff at the hospital decided to put in place one-to-one supervision. An omission in recording that plan in Ms de Ceita’s medical records by hospital staff led to that plan being affected which in turn led to Ms de Ceita subsequently falling by her hospital bed and sustaining a fatal brain injury. The matter of concern is therefore the lack of an effective system to document and address the risk of elderly patients falling while in the hospital.
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, 2024-0455
- 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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