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recurance

Marvin Rue

3 Mar 2022 · Coroner Caroline Saunders · Gwent

The coroner's concerns

  1. 1. falls risk

    “[the deceased] had fallen prior to his admission to hospital on 8` January 2021 and was therefore, due to his age and circumstances, a”
  2. 2. lack of post-transfer risk assessment

    “a review of the MRFA should take place after every hospital transfer”
  3. 3. repeated falls without intervention

    “Mr [name redacted] fell 5 times priorto his fatal fall in hospital on 2nd February 2021”
  4. 4. inadequate nursing care

    “the staff were under significant pressure due to the effects of the pandemic, and I accept that. However the care that Mr [name redacted] was denied was basic nursing care”
  5. 5. lack of 1:1 supervision for high-risk patient

    “had Mr [name redacted] been assessed, he would have warranted 1:1 supervision”
  6. 6. absence of audit oversight

    “no evidence that audits were completed at this time”

Responses

No published response was found on judiciary.uk.

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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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Marvin Rue · Recurance