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recurance

Margaret Burman

17 Apr 2024 · Coroner David Ridley · Wiltshire and Swindon

The coroner's concerns

  1. 1. inappropriate staffing leading to falls

    “falls in the hospital environment do happen, however, I was of the view in Avril's case that had there been an appropriate Healthcare Assistant present then Avril's fall and death more likely than not would have been avoided.”
  2. 2. risk of traumatic fatal injury from falls

    “the elderly on hospital wards are at significant risk of sustaining a traumatic and fatal injury by having a fall on a ward due to the unavailability of appropriate and necessary falls mitigation measures”
  3. 3. lack of national standardised falls assessment toolkit

    “there should be national leadership and a standardised toolkit when assessing falls risks on hospital wards and that there should also be a greater degree sharing of learning where methods of good practice have been adopted by other Trusts that could easily be adopted by Trusts where this is a challenge”

Responses

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Source: Prevention of Future Deaths reports and responses published by the Courts and Tribunals Judiciary at judiciary.uk. Crown copyright, used under the Open Government Licence v3.0. Data updated 26 Oct 2026.

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