Mary Pomeroy
1 Apr 2025 · Coroner Nicholas Lane · Devon, Plymouth and Torbay
The coroner's concerns
1. patient pushing incidents on ward
“Derriford Hospital in Plymouth is the main acute hospital site managed by UHP NHS”
2. untreated psychiatric symptoms leading to aggression
“patient who pushed [the deceased] had been involved in a number of incidents where he had used physical force on staff members on the ward in February 2022.”
3. repeated physical aggression toward staff
“Pomeroy had been involved in a number of incidents where he had used physical force on staff members on the ward in February 2022. At”
4. lack of enhanced monitoring of high-risk patient
“Pomeroy should, on 3 March 2022, have been subject to enhanced observations of care -”
5. inadequate risk assessment in RCA
“UHP NHS's RCA report had been incorrect to conclude that the type of incident that occurred on 3 March 2022 could not have been foreseen”
6. inadequate behavioural management
“lack of assessment and management of this patient's behaviour and needs materially contributed to the incident which led to [the deceased] suffering injuries and led to her death”