Malcolm Welch
11 Mar 2026 · Coroner Mark Armitage · North Yorkshire and York
The coroner's concerns
1. lack of allocated walking frame
“it is likely that the deceased had been on Ward 35 for around 2 hours and 40 minutes and he still had not been provided with an allocated walking frame for his own use”
2. absence of documented mobility aid provision
“the clinical notes did not refer to him having been provided with that mobility aid”
3. inconsistent reassessment of mobility needs across wards
“a reassessment would be undertaken on admission to a new ward and a decision would then be taken in relation to the provision of such mobility aids”
4. use of inappropriate or shared mobility aid
“this lack of a walking frame contributed to the deceased's fall, given that he likely used a frame belonging to someone else”
5. inconsistent mobility aid provision
“concerned about the consistency of the provision of such mobility aids during the course of a patient's admission”