“Firstly, I have heard that the Datix report for Mr Fallows' first fall on 12 February was…”

The coroner’s concerns

– 1. Firstly, I have heard that the Datix report for Mr Fallows' first fall on 12 February was not completed at the time by staff, and the nurse in question is now retired and thus it was not possible to ascertain why it had not been completed. The report was only completed retrospectively two months later by staff once an inquest had been opened and a request for evidence was sent to the Trust. A Datix is a risk management information system which gathers information on processes and errors and allows staff to report on any issue which may compromise patient safety, which is central to good clinical governance and best practice, as well as contributing to learning. Whilst the failure to create the DATIX here could be a oneoff, I am concerned that staff may not be aware of the importance of completing these reports and doing so in a timely fashion, which I understand should be completed within 24 hours of incident or knowledge of an incident. It is not difficult to see that where incidents are not being logged and reviewed, patient safety could be compromised, and future deaths could occur as a consequence; 2. Secondly, I was concerned to read that the Datix relating to the fall of 12 February (code U454194) appears to have undergone some kind of automated approval and sign off process in June 2024, and regrettably staff were unable to shed any light during the inquest on what happened/happens during this process. This is in contrast to the Datix relating to the second fall (code U441480) which appears to have gone through a “manual” approval and sign off process and the matter closed on 06/06/20204 (with the name of the approver being redacted on the form). I am concerned that if the Trust has any kind of automation process for the review and approval of Datix reports, there may be missed opportunities for humans to correctly identify any incident that compromises patient safety and which give rise to a risk of death; 3. Thirdly, I was concerned to hear from Senior Ward Sister that nursing staff utilise templates or pro-forma text when completing DATIX reports. The use of templates, whilst time saving, can easily lead to incorrect or incomplete information being provided on incidents (as happened in Mr Fallows' care) and therefore there is a real risk that opportunities will be lost to correctly investigate incidents which affect patient safety and which may cause a risk of 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, 2024-0458

Added to Minute Book

8 Oct 2026

Reuse

We show short extracts and link to the original. We don’t host the full report.

Something wrong, such as a date or who it was sent to? Report a mistake

Is this report about someone close to you? You can ask us to remove names from our pages.

Contains public sector information licensed under the Open Government Licence v3.0. Source: Courts and Tribunals Judiciary, judiciary.uk. Open Government Licence v3.0