Recurance · prevention of future deaths reports
Pre-inquest brief
The earlier warning
Robert Taylor · 22 Oct 2024 · Louise Hunt, Birmingham and Solihull
“The central issue in this case relating to the fall on 11/06/24 was the lack of enhanced nursing observations.”
judiciary.uk/…/robert-taylor-prevention-of-future-deaths-report…
What was promised
Stated action 1 · response to Robert Taylor (22 Oct 2024) · stated timescale: none stated
“The Enhanced Care policy has been re-embedded into the ward and risks are discussed in the ward huddle following shift handovers.”
judiciary.uk/…/2024-0567-Response-from-University-Hospitals-Bir…
Stated action 2 · response to Robert Taylor (22 Oct 2024) · stated timescale: none stated
“Acuity was noted to be a contributing factor within this case. There is currently a SNCT (Safer Nursing Care Tool) to review of acuity levels as part of the wider Trust review of acuity and dependency.”
judiciary.uk/…/2024-0567-Response-from-University-Hospitals-Bir…
Stated action 3 · response to Robert Taylor (22 Oct 2024) · stated timescale: none stated
“The nurse in charge currently identifies and discusses patients at risk of falls, as well as those requiring enhanced observations, with the Matron, prior to the 0800- touchpoint meeting.”
judiciary.uk/…/2024-0567-Response-from-University-Hospitals-Bir…
3 further stated actions are listed on the full chain page.
What recurred
- 1 May 2026 · John McKinlay · Emma Brown · Identical hazard · confidence 0.90 (high)
The clearest link, quoted from both reports:
Earlier · Robert Taylor · 22 Oct 2024
“The central issue in this case relating to the fall on 11/06/24 was the lack of enhanced nursing observations.”
Later · John McKinlay · 1 May 2026
“Some, potentially all, of these falls occurred when Mr [name redacted] was not receiving the appropriate level of observation in accordance with his falls risk assessment and care plan.”
What happened next
No web check of the stated actions has been published for this chain.