Prevention of Future Deaths reports · 2024

Alan Fallows

Regulation 28 report to prevent future deaths, reference 2024-0458, written 19 Aug 2024. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.

Date of report19 Aug 2024
Reference2024-0458
DeceasedAlan Fallows
CoronerAdam Hodson
Coroner areaBirmingham and Solihull
CategoryHospital Death (Clinical Procedures and medical management) related deaths
Sourcejudiciary.uk record · original PDF
Responses published1

The report

Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.

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REGULATION 28 REPORT TO PREVENT FUTURE DEATHS 

THIS REPORT IS BEING SENT TO:  University Hospitals Birmingham 
CORONER 

 I am Mr Adam Hodson, Assistant Coroner  for Birmingham and Solihull 
CORONER’S LEGAL POWERS 

 I make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and 
regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. 
INVESTIGATION and INQUEST 

 On 11 April 2024 I commenced an investigation into the death of Alan Stanley FALLOWS. The 
investigation concluded at the end of the inquest . The conclusion of the inquest was; Death due to 
natural causes, contributed to by injuries sustained from an in-patient fall whilst in hospital 

CIRCUMSTANCES OF THE DEATH  

Mr Fallows was admitted into Good Hope Hospital in Birmingham on 08/02/2024 following a 
fall at home and was diagnosed as having sustained a suspected broken elbow as well as 
having postural hypotension. He was initially discharged but readmitted on 09/02/2024 due 
to a CT scan showing a chronic subdural haematoma. On 10/02/2024 a falls assessment 
was incorrectly completed but which still deemed him to be at high risk of falls, and on 
12/02/2024 bed rails were put in place following an assessment. Later that day he had an 
unwitnessed fall but did not sustain injuries. His falls risk assessment was not updated 
following this fall, although his bed rails assessment was updated three days later on 
15/02/2024. On 16/02/2024, he had a further unwitnessed fall and suffered a minor head 
injury and a fracture to his right neck of femur. On 17/02/2024 he was transported to 
Birmingham Heartlands Hospital for surgery which was uneventful. On 02/03/2024, he was 
transferred to Solihull Hospital for physiotherapy, but subsequently developed severe 
bilateral aspiration pneumonia. Despite optimal treatment, his condition deteriorated over 
the course of three weeks, and he sadly died on 28/03/2024. Although gaps in care were 
identified, it is impossible to say whether his falls could have been prevented. 

 Based on information from the Deceased’s treating clinicians the medical cause of death was 
determined to be: 

 1a Aspiration pneumonia   

 1b Frailty of old age   

 1c    

 II    Fracture right neck of femur (operated), Chronic obstructive pulmonary disease 
CORONER’S CONCERNS 

 During the course of the inquest the evidence revealed matters giving rise to concern. In my 
opinion there is a risk that future deaths will occur unless action is taken. In the circumstances it is 
my statutory duty to report to you. 

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 The MATTERS OF CONCERN are as follows.  – 

  
  
  
  
  
 
 1.  Firstly, I have heard that the Datix report for Mr Fallows' first fall on 12 February was 
not completed at the time by staff, and the nurse in question is now retired and thus 
it was not possible to ascertain why it had not been completed. The report was only 
completed retrospectively two months later by staff once an inquest had been 
opened and a request for evidence was sent to the Trust. A Datix is a risk 
management information system which gathers information on processes and 
errors and allows staff to report on any issue which may compromise patient safety, 
which is central to good clinical governance and best practice, as well as 
contributing to learning. Whilst the failure to create the DATIX here could be a one-
off, I am concerned that staff may not be aware of the importance of completing 
these reports and doing so in a timely fashion, which I understand should be 
completed within 24 hours of incident or knowledge of an incident. It is not difficult 
to see that where incidents are not being logged and reviewed, patient safety could 
be compromised, and future deaths could occur as a consequence; 

2.  Secondly, I was concerned to read that the Datix relating to the fall of 12 February 

(code U454194) appears to have undergone some kind of automated approval and 
sign off process in June 2024, and regrettably staff were unable to shed any light 
during the inquest on what happened/happens during this process. This is in 
contrast to the Datix relating to the second fall (code U441480) which appears to 
have gone through a “manual” approval and sign off process and the matter closed 
on 06/06/20204 (with the name of the approver being redacted on the form). I am 
concerned that if the Trust has any kind of automation process for the review and 
approval of Datix reports, there may be missed opportunities for humans to correctly 
identify any incident that compromises patient safety and which give rise to a risk of 
death; 

3.  Thirdly, I was concerned to hear from Senior Ward Sister 

 that nursing 

staff utilise templates or pro-forma text when completing DATIX reports. The use of 
templates, whilst time saving, can easily lead to incorrect or incomplete information 
being provided on incidents (as happened in Mr Fallows' care) and therefore there 
is a real risk that opportunities will be lost to correctly investigate incidents which 
affect patient safety and which may cause a risk of death. 

ACTION SHOULD BE TAKEN 

 In my opinion action should be taken to prevent future deaths and I believe you have the power to 
take such action. 

YOUR RESPONSE 

 You are under a duty to respond to this report within 56 days of the date of this report, namely by 
14 October 2024. I, the coroner, may extend the period. 

Your response must contain details of action taken or proposed to be taken, setting out the 
timetable for action. Otherwise, you must explain why no action is proposed.  

COPIES and PUBLICATION 

 I have sent a copy of my report to the Chief Coroner and to the following Interested Persons: 

The family of Mr Fallows 

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  I have also sent it to the Medical Examiner, ICS, NHS England, CQC, who may find it useful or of 
interest. 

 I am also under a duty to send the Chief Coroner a copy of your response. 

 The Chief Coroner may publish either or both in a complete or redacted or summary form. He may 
send a copy of this report to any person who he believes may find it useful or of interest. You may 
make representations to me, the coroner, at the time of your response, about the release or the 
publication of your response by the Chief Coroner. 
 19 August 2024  

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Signature:  

Adam Hodson 

Assistant Coroner for Birmingham and Solihull

Responses

1 response published against this report on judiciary.uk. A response is a body's written reply to the coroner's concerns; publication is at the discretion of the Chief Coroner's office, so an absent response does not mean nobody replied.

Response from University Hospitals Birmingham (PDF)
Sent by way of email only: 

Dear Mr Hodson, 

Inquest touching the death of Alan Stanley Fallows 

Response to Regulation 28 Report to prevent future deaths 

I am writing in response to the Regulation 28 notice issued following the conclusion of the 
inquest on 15 August 2024 touching the death of Mr Fallows who died on 28 March 2024 at 
Good Hope Hospital (part of University Hospitals Birmingham NHS Foundation Trust (UHB)).  

We have carefully considered the concerns raised within your report to prevent future deaths 
and would respond as follows: 

Reporting of incidents retrospectively 

You heard evidence that following Mr Fallows' fall on 12 February 2024 an incident report 
form was not completed at that time and that the incident was reported retrospectively upon 
an Inquest being opened and statements being requested.  

We have been unable to identify why an incident report wasn’t completed at the time of the 

fall as the member of staff has retired however retrospectively reporting an incident is 
expected if the incident had not been reported at the time.   

An analysis of reporting data based on a 12 month period of falls across UHB demonstrates 
that falls were reported: 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 a) 

b) 

c) 

Same day – 86.4% 

The following day – 98.4% 

Within 2 days – 99.1% 

The above data provides assurance that most falls are reported within 2 days.  Whilst the 
data is reassuring, we have updated the training provided by our falls team to reinforce the 
reporting requirements following a fall.  

Automated approval of incident  

During the Inquest you raised a concern in relation to an automated approval and sign off 
process of incidents.  In this case, the incident report relating to Mr Fallows fall on 12 
February 2024 recorded the final approver as ‘automated’ which was in contrast to Mr 
Fallows second fall which included details of a named ‘final approver’.  

All reported incidents are reviewed by an individual before the approval and sign off/closure 
process.  We do not have an automated approval and sign off process for incidents and all 
incidents are closed following review by an individual.  For low level incidents, such as the 
incident relating to the first fall where the level of harm is low, these incidents are closed 
following review by a local manager.  Following this review an automatic closure process is 
run which ‘stamps’ the record with the final approver as ‘automated’.   

Where the level of harm is moderate or above, these are reviewed by a member of the 
Clinical Governance and Patient Safety team prior to closure and the governance lead within 
this department will be named as the final approver. 

In all cases, there is a manual review before an incident is closed. 

In addition to the above review, our falls team review every incident report form, relating to a 
patient fall, on a daily basis.  The team review the incident, the patient record which includes 
a review of the post-fall assessment, to identify if there has been patient harm.  The incident 
report form is also reviewed by the senior nurse/ward manager which ensures there is 
appropriate review following a patient fall. 

 
 
 
 
 
 
 
 
 
 Use of templates when completing DATIX reports 

You heard evidence from the Senior Ward Sister that nursing staff utilise templates or pro-
forma text when completing DATIX reports [incident reports] and you are concerned that this 
approach may lead to incorrect or incomplete information being recorded.  

We can confirm that we do not have a template list of actions for incident report forms.  
Within our electronic patient record there is a post-fall section in the daily care plan which 
includes a number of actions that staff must take following a fall which includes; ensuring 
that neurological observations have been commenced, ensuring that an incident form has 
been submitted, ensuring that the Next of Kin have been informed etc.  In this case the 
Senior Sister used a set list of actions to ensure all necessary falls prevention interventions 
were in place.  I can provide assurance that templates are not used. 

In addition to the above, the daily review of incidents undertaken by the falls team acts as an 
additional independent individualised review. 

I would like to assure you that the concerns raised within the Regulation 28 Report have 
been thoroughly investigated and I hope the information provided above provides 
reassurance to you of the processes that are in place. 

Yours sincerely 

, 

Deputy CEO and Chief Medical Officer

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