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recurance

Raymond Eggleton

17 Nov 2023 · Coroner David Ridley · Wiltshire and Swindon

The coroner's concerns

  1. 1. falls in hospital environment

    “Falls in the hospital environment do happen and I am not saying that all can be avoided. That having been said what I have noted of late when dealing with these cases is an increase in the instances where as a result of my investigation, in relation to cases that I have been directly involved in, that I am making findings that more likely than not the falls could have been prevented and the injuries that were causative in relation to that individuals death, avoided.”
  2. 2. incorrect falls risk assessment

    “initial falls risk assessment on LAMU which was not undertaken taking advantage of all available information which in my view led to an incorrect assessment of Ray's supervision needs”
  3. 3. lack of dynamic response to patient risk

    “ongoing programme, the Enhanced Care Toolkit Framework, which I acknowledge is work in progress, in respect of which not only the family but also I am interested in hearing what steps the Trust intends to take to mitigate against a risk of further incidents occurring such as the fall that Ray had on the night of 17th/18th of January”

Responses

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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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