“is as follows”
Dated 22 Oct 2024, from the coroner for Birmingham and Solihull. 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 17 Dec 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 dated22 Oct 2024
- Deadline17 Dec 2024
- Published on judiciary.uk24 Oct 2024
- Today23 Oct 2026
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Responses from each recipient
| Sent to | Response |
|---|---|
| University Hospitals Birmingham NHS Foundation Trust | Response publishedPublished on judiciary.uk in October 2024. |
The coroner’s concerns
is as follows. – 5 1. The central issue in this case relating to the fall on 11/06/24 was the lack of enhanced nursing observations. The Nursing witness was unable to say what steps, if any, had been taken to try to put enhanced observations in place. The Investigation report stated that enhanced observations had been identified as needed but did not expand on what actions were taken, if any, to obtain enhanced observation nor what actions had been taken after the death to ensure enhanced observations for patients that require them. This raises a concern for future deaths. 2. The witnesses and the investigation report did not address the central issue relating to the fall and this raises a concern about the quality of post death investigations being undertaken by the Trust. This raises a concern for future deaths.
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, 2024-0567
- Added to Minute Book
- 8 Oct 2026
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- 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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