“are, as follows: 1”

The coroner’s concerns

are, as follows: 1. The consultant geriatrician’s evidence was that CT scan was requested to take place ‘as soon as possible’ following the first unwitnessed fall on 25 July 2024; however, they accepted that this was not conducted in a timely manner. Further, following the second unwitnessed fall on 28 July 2024, there was a further delay in a CT scan taking place. I was told that this scan should have been conducted within 1-2 hours of the request being made, yet it took place over three hours after the patient was reviewed by the doctor and the request for the scan was made. In Mr Eastman’s case, the delays in receiving the scans transpired to be immaterial in the particular circumstances. However, I am concerned that if delays in such scans, where traumatic injury is suspected, are repeated in the future, there is a risk that deaths could occur. 2. There was evidence of what I considered to be ‘widespread communication issues’ in the care provided to Mr Eastman. These included: • When the on-call doctor attended to review Mr Eastman at approximately 02:45 on 28 July 2024, ward staff (incorrectly) told the doctor that nobody had fallen on the ward, which lead to the doctor leaving the ward without Mr Eastman having been reviewed. As the consultant geriatrician said in his evidence, communication between the ward staff and medical staff was not good. The evidence revealed that there were deficiencies in basic record keeping. 3. As set out above, there was clear evidence that the Trust has put extensive measures in place to address the issue of staff having not followed the Trust’s own post-fall procedures and protocols. However, I am concerned that the issue may not be limited to just those particular protocols and may be indicative of a wider skills/knowledge deficit. 4. Following on from the matter set out in paragraph 3 above, the evidence revealed a lack of professional curiosity on the part of some staff members (nursing and medical). In my view, this could also be indicative of an underlying skills/knowledge deficit. 6.

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, 2025-0093

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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