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recurance

John Long

14 Jan 2020 · Coroner Russell Caller · London Inner (West)

The coroner's concerns

  1. 1. patient falls from bed

    “The bed rails affixed to patients beds allow a patient to fall easily from the patient's bed and the make and manufacture of bed rails should be reviewed to ensure they are fit for purpose and act to ensure the patient is secure in their bed and also prevent a patient accidentally falling from their bed.”
  2. 2. inadequate 1:1 care management

    “A review is required into the use of 1:1 (one to one) care in hospital wards and in particular a review into the definition of what 1:1 (one to one) care actually means. In addition a review on how it is administered on the ward and what rules there are for those nurses and Carers to comply with when carrying out such care for a patient. Furthermore there needs to be very clear rules about how Carer or nurse carrying out such care ensures they have sufficient breaks from providing such care and”
  3. 3. inadequate training of 1:1 care

    “A review is required on how training of 1: 1 (one to one) care is implemented And administered on a hospital ward and also how such training is communicated to nurses and Carers.”

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.

A link shows that a similar concern was raised again, not why. It is not a finding about any organisation or person. Methodology and responsible use · Report an error