John McKinlay
1 May 2026 · Coroner Emma Brown · Birmingham and Solihull
This report repeats 1 earlier warning. See the linked reports.
The coroner's concerns
1. inadequate supervision of inpatient falls
“The evidence from witnesses was that Mr [name redacted] had a total of 4 falls whilst an inpatient at the University Hospitals of Birmingham: on the 11th September 2025 at Good Hope Hospital, 28th September 2025 at Birmingham Heartlands Hospital and on the 10th and 12th November 2025 at Queen Elizabeth Hospital. 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.”
2. fractured neck of femur and subdural haemorrhage
“He sustained a femur fracture requiring operative fixation from the fall on the 11th September and an acute bleed of a pre-existing subdural haemorrhage on the 28th September.”
3. lack of investigation into inpatient falls
“There has been a mortality review of the events at Good Hope Hospital, including the fall on the 11th September. However, evidence has not been provided of investigations into the falls at Birmingham Heartlands Hospital and Queen Elizabeth Hospital.”
Linked reports
Identical hazardConfidence 0.90 · high
Earlier report
“The central issue in this case relating to the fall on 11/06/24 was the lack of enhanced nursing observations.”
This report
“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.”