Prevention of Future Deaths reports · 2024

Margaret Maycroft

Regulation 28 report to prevent future deaths, reference 2024-0509, written 20 Sep 2024. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.

Date of report20 Sep 2024
Reference2024-0509
DeceasedMargaret Maycroft
CoronerDavid Reid
Coroner areaWorcestershire
CategoryHospital Death (Clinical Procedures and medical management) related deaths
Organisation namedWorcestershire Acute Hospitals NHS Trust
Sourcejudiciary.uk record · original PDF
Responses published1

The report

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

REGULATION 28 REPORT TO PREVENT FUTURE DEATHS 

THIS REPORT IS BEING SENT TO: 

, Chief Executive, Worcestershire Acute Hospitals NHS Trust, 

Charles Hastings Way, Worcester WR5 1DD; 

1  CORONER 

I am David Donald William REID, HM Senior Coroner for Worcestershire. 

2  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. 

http://www.legislation.gov.uk/ukpga/2009/25/schedule/5/paragraph/7 
http://www.legislation.gov.uk/uksi/2013/1629/part/7/made 

3 

INVESTIGATION and INQUEST 

On 31 January 2024 I commenced an investigation and opened an inquest into the 
death of Margaret Rose MAYCROFT. The investigation concluded at the end of the 
inquest on 12 September 2024. 

The conclusion of the inquest was that Ms. Maycroft “Died from natural causes, to 
which injuries sustained in a number of recent accidental falls contributed.” 

4  CIRCUMSTANCES OF THE DEATH 

In answer to the questions “when, where and how did Ms. Maycroft come by her 
death?”, I recorded as follows: 

“On 18.12.23 Margaret Maycroft, who had recently suffered a number of falls at home, 
which had caused an intracranial bleed, and on a hospital ward during a previous 
admission, was readmitted to Worcestershire Royal Hospital and found to have 
suffered an ischaemic stroke. During this admission, she suffered two further falls and 
was found to have sustained a displaced fractured neck of femur. She underwent 
surgery to repair this fracture, but thereafter continued to decline. She was transferred 
to the Princess of Wales Community Hospital, Bromsgrove for palliative care, and 
declined and died there on 27.1.24.” 

5  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. 

The MATTERS OF CONCERN are as follows.  –  

1)  While at Worcestershire Royal Hospital, Ms. Maycroft sustained a number of 

falls: 
(a)  on 5.12.23 in the Emergency Department; 
(b)  on 19.12.23 in the Emergency Department; 
(c)  on 23.12.23 in the Acute Frailty Unit. 

1 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 2) 

In respect of each of these falls, Matron 
whilst staff in the Emergency Department and the Acute Frailty Unit had 
completed falls risk assessments, no measures to mitigate that risk, such as 
might be found in a falls prevention, assessment and intervention plan, were 
documented in Ms. Maycroft’s notes. This meant that no documented falls 
prevention measures were put in place for her. 

 gave evidence that 

3)  Furthermore, I heard no evidence at the inquest which satisfied me that steps  
have now been taken to ensure falls prevention measures are now being 
properly considered and documented in both the Emergency Department and 
the Acute Frailty Unit at the hospital.  

6  ACTION SHOULD BE TAKEN 

In my opinion action should be taken to prevent future deaths and I believe you, as 
the Chief Executive of Worcestershire Acute Hospitals NHS Trust have the power to 
take such action.    

7 

YOUR RESPONSE 

You are under a duty to respond to this report within 56 days of the date of this report, 
namely by 15 November 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. 

8  COPIES and PUBLICATION 

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

(a) 

, Ms. Maycroft’s nephew. 

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.  

9 

20 September 2024 

David REID 
HM Senior Coroner for Worcestershire 

2

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 Worcestershire Acute Hospitals NHS Trust (PDF)
08 November 2024 

Mr David Reid 
HM Senior Coroner 
Worcestershire Coroners Court 
The Civic 
Martin’s Way 
Stourport on Severn 
Worcestershire 

Sent via email:  

Dear Mr Reid 

Re Regulation 28 Report to Prevent Future Deaths  

Please accept this letter in response to your Regulation 28 Report to Prevent Future Deaths 
received  on  the  26th  September  2024,  following  the  Inquest  touching  on  the  death  of  Mrs 
Margaret Maycroft  

In your  Regulation 28 report,  you  identified the  following  matters  of  concern  relating to  the 
Worcestershire Acute Hospitals NHS Trust (WAHT). 

1) 

While  at  Worcestershire  Royal  Hospital,  Ms.  Maycroft  sustained  a  number  of 
falls: 

(a) 

on 5.12.23 in the Emergency Department; 

(b) 

on 19.12.23 in the Emergency Department; 

(c) 

on 23.12.23 in the Acute Frailty Unit. 

2) 

3) 

In respect of each of these falls, Matron Claire James gave evidence that whilst 
staff  in  the  Emergency  Department  (ED)  and  the  Acute  Frailty  Unit  had 
completed  falls  risk  assessments,  no  measures  to  mitigate  that  risk,  such  as 
might  be  found  in  a  falls  prevention,  assessment  and  intervention  plan,  were 
documented  in  Ms.  Maycroft's  notes.  This  meant  that  no  documented  falls 
prevention measures were put in place for her. 

Furthermore, I heard no evidence at the inquest which satisfied me that steps 
have  now  been  taken  to  ensure  falls  prevention  measures  are  now  being 
properly  considered  and  documented in both the  Emergency  Department  and 
the Acute Frailty Unit at the hospital. 

  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 RESPONSE: 

•  The Trust is compliant with NICE Guidance for falls risk assessment.  
•  The Trust set its own metric to complete the Risk assessment (RA) within 4 hours, this is 
for  patients  admitted,  not  those  in  ED.    The  Trust  has  recognised  patients  are  staying 
longer than anticipated in ED and ED have developed a risk assessment and processes 
to cover that period which sits within the ED nursing paperwork, however the ED are going 
live with EPR in November which will allow ED to complete the same assessments as the 
rest of the trust and make it visible to the receiving ward.  

•  There  has  been  a  6-month  deep  dive  review  of  all  falls  in  A&E  and  AMU  -  preliminary 
findings show – of 112 falls, 3 resulted in moderate harm. The findings of the deep dive 
were presented to the Quality Governance Committee on 31st October. 

•  The number of all falls occurring in ED equates to 0.3% of the total ED attendances in that 

time period  

Percentage of Falls in ED against attendance 

Site 

Ward 

Apr-24 

May-
24 

Jun-24  Jul-24 

Aug-
24 

Sep-24  Total 

Accident 
Emergency 

Accident 
Emergency 

& 

& 

ALEX 

WRH  

Trust 

0.3% 

0.2% 

0.2% 

0.2% 

0.4% 

0.6% 

0.3% 

0.3% 

0.2% 

0.3% 

0.3% 

0.3% 

0.3% 

0.3% 

0.3% 

0.2% 

0.3% 

0.3% 

0.4% 

0.4% 

0.3% 

•  There are trust wide falls prevention measures in place and work is being undertaken to 
review the post fall record and intervention document on the electronic patient record and 
for the expectations around completion to be clarified. 

•  The  barriers  faced  by  staff  in  documenting  falls  interventions  in  place  on  EPR  will  be 
explored and actions taken and monitored through Improving Safety Action Group (ISAG) 

•  The EPR team will distribute an update on how to document interventions on Sunrise.  
•  There  is  a  trust-wide  audit  in  place  (Quality  Checks)  which  is  completed  weekly  and 
requires a check of “are falls measures/interventions in place?” and is further scrutinised 
in the Fundamentals of Care Committee (FoCC) which is chaired by one of the Deputy 
Chief Nursing Officers.  

Actions taken in the ED: 

• 

Introduction of yellow falls bundle in ED (yellow blanket / socks to highlight patients 
at risk visually)  

•  Falls risk assessments now added in to ED Nursing packs (as they had previously 

not been due to it not being an admitting area 

•  1:1 enhanced care tabards are now used in ED (to highlight the staff supervising 

falls risk patients to reduce the risk of them being distracted by other staff) 

  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 • 

Introduced safety huddles throughout the day lead by the band 7 – Patients at risk 
of falls discussed – verbally remind each other. 

Actions taken in AFU: 

•  Discussed in safety huddles if the patient is identified as a high falls risk 
•  AFU staff have been reminded that they have the use of 6 Ramble Guard devices which 
are  allocated  to  high-risk  patients  and  those  that  are  at  risk  but  maybe  not  able  to  be 
located  in  the  high  visibility  bays  (due  to  infection  prevention  /  gender  mix  of  bay  or 
capacity) 

•  The high visibility bays operate a ‘stay in the bay’ function - allocation to these bays would 

be dependent on the assessment of all patients at risk of falls on the unit. 

•  Those patients unable to be allocated a high visibility bed or a ramble guard unit may be 

suitable for 1:1 supervision which would get arranged accordingly. 

•  Staff risk assess patients on arrival to AFU 
•  Gripper socks are also available for at risk patients who are mobile. 

Actions taken trust-wide: 

•  Falls that have occurred are discussed at the ward MDT Board Round to identify 

any additional local interventions required 

•  Staff  training  has  been  enhanced  through  falls  simulation  sessions  to  better 

manage high-risk patients. 

•  There are initiatives being implemented to enhance the quality of multifactorial falls 
risk  assessment,  particularly  focusing  on  lying  and  standing  blood  pressure 
measurements which are detailed specifically in the FoCC monthly update. 

•  There  has  been  a  review  of  lifting  equipment  resulting  in  the  procurement  of 
devices for the Worcestershire Royal Site, with training provided by the Moving & 
Handling Team. 

Trust-wide measures to monitor and review controls and actions: 

•  There is a mechanism for all ward managers to monitor falls interventions on EPR and 
audit their falls documentation  – these are reviewed in the weekly check and challenge 
forum. 

•  Check  and  challenge  –  are  meetings  with  the  DCNO,  falls  lead  and  the  ward 
manager/matron of the ward the fall occurred on.  They talk through what happened, and 
any omissions in care and learning and identify on areas for learning or improvement.   
•  Falls are also discussed weekly via the CNO production board to identify any immediate 
action / support needed and identify any area require additional resource or focus  – this 
production board also happens at divisional level with Matrons required to give assurance 
to Divisional Directors of Nursing following any inpatient falls. 

•  The  IPR  is  the  integrated  performance  review  that  is  shared  at  QGC  and  Trust  Board, 
includes  a  section  on  quality  and  safety.   This  now  includes  any  falls  with  moderate  or 
above harm.  

I hope that the above addresses the concerns which you raised.  I have no representations in 
respect of publication of the Regulation 28 or this response by the Chief Coroner. 

  
 
 
 
 
 
 
 I  shall  be  grateful  if  you  could kindly  send a  copy of my  response to anyone  to whom  you 
copied your Regulation 28 report.  

Yours sincerely                   

Chief Executive

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