Prevention of Future Deaths reports · 2025
Regulation 28 report to prevent future deaths, reference 2025-0607, written 4 Dec 2025. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 4 Dec 2025 |
|---|---|
| Reference | 2025-0607 |
| Deceased | Lina Piroli |
| Coroner | Melanie Lee |
| Coroner area | Inner North London |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 2 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
Regulation 28: Prevention of Future Deaths report
Lina Piroli (died 20 February 2025)
THIS REPORT IS BEING SENT TO:
1. NHS England
2. Department of Health and Social Care
1
CORONER
I am: Melanie Sarah Lee
Assistant Coroner
Inner North London
St Pancras Coroner’s Court
Camley Street
London N1C 4PP
2
CORONER’S LEGAL POWERS
I make this report under the Coroners and Justice Act 2009,
paragraph 7, Schedule 5, and The Coroners (Investigations)
Regulations 2013, regulations 28 and 29.
3
INVESTIGATION and INQUEST
On 24 February an investigation commenced into the death of Lina
Piroli, age 93 years. The investigation concluded at the end of the
inquest on 1 December 2025. I made a determination at inquest that
Lina Piroli suffered a multifactorial fall contributed to by naturally
occurring age-related disease processes and an E. coli infection.
4
CIRCUMSTANCES OF THE DEATH
Lina Piroli presented to the Whittington Hospital on 1 February 2025
with a two week history of feeling unwell, including a dry cough. Whilst
a chest X-ray was clear, she had a raised heart rate, raised respiration
rate, a temperature and slightly raised inflammatory markers. She was
treated with IV antibiotics and fluids for a suspected chest infection and
was discharged home on oral antibiotics in thee early hours of 2
February. Microbiology culture results were awaited. Lina re-presented
to A&E by ambulance that evening following a fall down stairs at home.
She was found to have an unstable fracture of C2 and a stable fracture
of L1. Whilst in A&E, microbiology results were returned indicating an
E.coli infection which was later confirmed, although the location of the
1
infection was never established. She was already on the correct
antibiotics and so treatment continued. After a long stay in A&E due to
lack of a bed, Lina was transferred to a ward. Her pain and swallow
were difficult to manage and she was presenting with delirium. She was
unable to tolerate the hard collar and did not respond clinically to
ongoing antibiotic treatment. Due to her age and frailty, her treatment
became focused on comfort and she died whilst still an inpatient at the
Whittington Hospital on 20 February 2025.
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.
When Lina presented to the Whittington Hospital on the evening of 2
February 2025 it was identified that due to her fractured spine, she would
need a bed on an elderly care ward. She was accepted by the medical
team but there were no beds available. This meant that she remained in
A&E at a time when she was experiencing pain, confusion and delirium
due to her injury, infection, pain, pain medication and dementia. I heard
that there is guidance on how to treat people with dementia during a
hospital admission but that this is simply not unachievable in a busy and
overcrowded emergency department. Lina was a complex presentation
and 93 years old.
Whilst Lina received the immediately necessary tests and treatment, she
was not seen by the geriatric team (who do not work in A&E) and had
delayed access to specialist nurses, robust symptom control measures,
regular reviews and coordinated care. She remained in a busy, noisy and
frightening environment. It was not until she was moved to a ward that
advice was sought on the best management of her spinal fracture. The
delay in transferring her to a ward was detrimental to optimising her
chances of recovery.
I heard evidence that this is not uncommon at the Whittington and is a
problem across all London hospitals (and hospitals throughout the UK).
When there are no ward beds to transfer patients to, they stay in A&E
and A&E is not set up to deliver the care that, particularly elderly and
complex medical, patients require. Nursing staff are having to treat
double the number of patients that the department is designed to
accommodate and patients who require care and treatment outside of
their expertise. This means that patients are not receiving the appropriate
level of care.
6
ACTION SHOULD BE TAKEN
2
In my opinion, action should be taken to prevent future deaths and I
believe that you and/or your organisation 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 29 January 2026. 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 following.
• Family of Lina Piroli
• Whittington Health NHS Trust
• HHJ Alexia Durran, the Chief Coroner of England & Wales
I am also under a duty to send a copy of your response to the Chief
Coroner and all interested persons who in my opinion should receive it.
I may also send a copy of your response to any other person who I
believe may find it useful or of interest.
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.
9
DATE SIGNED BY ASSISTANT CORONER
4 December 2025
3
2 responses 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.
Minister of State for Health (Secondary Care) 39 Victoria Street London SW1H 0EU 14 January 2026 Ms Melanie Sarah Lee Assistant Coroner Inner North London St Pancras Coroner’s Court Camley Street London N1C 4PP Dear Ms Lee, Thank you for the Regulation 28 report of 4 December 2025 sent to the Secretary of State regarding the death of Lina Piroli. I am replying as the Minister with responsibility for urgent and emergency care. Firstly, I would like to say how saddened I was to read of the circumstances of Ms Piroli’s death and I offer my sincere condolences to their family and loved ones. The circumstances your report describes are very concerning and I am grateful to you for bringing these matters to my attention. Please accept my sincere apologies for the delay in responding to this matter. The report raises concerns over A&E waiting times, hospital bed availability, and specialist care for the elderly. In preparing this response, my officials have made enquiries with NHS England and I understand they will be responding to your concerns in full. The Government acknowledges that urgent and emergency care (UEC) performance has not consistently met expectations in recent years. However, we are committed to ensuring patients receive the highest standard of service and care from the NHS. That is why our 10- Year Health Plan set out commitments to restoring waiting standards to those set out in the NHS Constitution by the end of this Parliament. We are taking serious steps to achieve this. Our Urgent and Emergency Care Plan for 2025/26 focuses on improvements to deliver better UEC performance both daily and during winter pressures, ensuring more patients receive timely and clinically appropriate care. We are aiming for 78% of patients to be seen in in 4 hours this year, meaning over 800,000 people will receive more timely care. Key actions to help achieve this include: • Investing £250 million into expanding same day and urgent care services, helping avoid unnecessary admissions to hospital and supporting faster diagnosis, treatment and discharge for patients. Increasing the number of patients receiving urgent care in primary, community and mental health settings. • • • • • Introducing new clinical operational standards for the first 72 hours of care to support better hospital flow. These set minimum expectations for timely review, availability of advice, and coordinated care when multiple specialist teams are involved. In the longer-term, our 10 Year Health Plan will increase the urgent care capacity outside hospital through new neighbourhood health services, reducing demand pressures on A&E. Improve hospital flow, with a focus on reducing the number of patients waiting more than 12 hours and making progress towards eliminating corridor care. Increasing bed capacity by reducing the average length of stay for patients requiring an overnight emergency admission by at least 0.4 days returning closer to pre- pandemic levels. Despite increasing demand, A&E 4-hour performance has improved, showing the measures we are taking are already having a positive impact. In England, the latest NHS figures show that in November 2025, 4-hour A&E performance improved to 74.2%, up from 72.2% in November last year. Regarding specialist care for the elderly, we recognise that older people are particularly vulnerable to long waits and delayed discharges. We are therefore investing in specialist frailty pathways, expanding the community workforce, and embedding elderly care expertise throughout urgent and emergency care. Initiatives such as frailty Same Day Emergency Care units, rapid front-door frailty team input, and integrated neighbourhood teams are designed to ensure older people receive timely, specialist assessment and support. We are also working to increase the number of geriatricians and frailty specialists, and to strengthen collaboration between hospital and community services, so that discharge planning starts earlier and transitions are safer. These actions are part of our wider commitment to transform care for older people and to ensure that the NHS meets the needs of an ageing population. I hope this response provides reassurance that the Government is taking meaningful action to improve urgent and emergency care services. Thank you once again for bringing these concerns to my attention. Yours sincerely, MINISTER OF STATE FOR HEALTH
Melanie Sarah Lee
Assistant Coroner
Inner North London
St Pancras Coroner’s Court
Camley Street
London
N1C 4PP
National Medical Director
NHS England
Wellington House
133-155 Waterloo Road
London
SE1 8UG
22nd January 2026
Dear Coroner,
Re: Regulation 28 Report to Prevent Future Deaths – Lina Piroli who died on
20th February 2025.
Thank you for your Report to Prevent Future Deaths (hereafter “Report”) dated 4th
December 2025 concerning the death of Lina Piroli on 20th February 2025. In advance
of responding to the specific concerns raised in your Report, I would like to express
my deep condolences to Lina’s family and loved ones. NHS England is keen to assure
the family and yourself that the concerns raised about Lina’s care have been listened
to and reflected upon.
Your Report raised concerns around the lack of available beds on the elderly care
ward at the time Lina re-presented to the Emergency Department (ED), and the delay
in transferring her to a ward. The busy and overcrowded ED meant that the guidance
on treating patients with dementia was unachievable. You raised that this is a problem
across all hospitals nationally and the ED is not set up to deliver care to elderly and
complex patients.
Emergency Department capacity and bed availability on wards
NHS England recognises the significant pressures on all NHS services and, in January
2023, published a two-year Urgent & Emergency Care (UEC) Recovery Plan. The plan
prioritised improvements to the 4-hour standard – a constitutional standard aiming for
95% of patients to be admitted, transferred, or discharged within four hours of arrival.
The plan outlined key actions to recover and improve urgent and emergency care
services. Despite significant challenges, including high demand for services, there was
an improvement in the headline ambition between 2023 and 2025.
Recognising that there is further work to be done, in June 2025, NHS England
published the Urgent and Emergency Care Plan for 2025/26 which included an
ambition to ‘improve flow through hospitals with a particular focus on patients waiting
over 12 hours and making progress on eliminating corridor care’. NHS England is
working with the regions to support Acute Trusts to eliminate crowding in EDs in the
longer term. Improvements are being progressed through NHS England’s operational
planning guidance, where Integrated Care Boards (ICBs) were asked to focus on
delivering improved patient flow. This has included increasing the productivity of acute
and non-acute healthcare services, improving flow and length of stay, as well as
clinical outcomes. In addition to this, we are continuing to develop services that shift
activity from acute hospital settings to settings outside of an acute hospital for patients
with unplanned urgent needs, supporting proactive care, alternatives to admission and
improving hospital discharge.
NHS England also undertook a bed occupancy reduction sprint to manage demand
nationally, which commenced in October 2025 and concluded on 24th December 2025.
This has enabled a reduced bed occupancy and enabled providers to respond to
surges in demand that the NHS traditionally experiences during winter, enabling
patients to move in a more timely manner to ward beds.
NHS England’s London regional team has liaised with the Whittington Hospital in
relation to this case. The Trust (Whittington Health NHS Trust) has advised that on 2nd
February 2025, when Lina presented to hospital, they were in a high Opel 3 (red alert)
status with 16 patients waiting for beds. An Opel 3 score signifies major operational
pressures, compromising patient flow. The Trust has a standard operating procedure
to support the care of patients waiting for beds, which sets out expected standards of
care.
Unfortunately, Lina’s stay in the ED was prolonged as she required neurosurgical
advice from the Royal London Hospital (RLH) and additional MRI imaging was
requested to identify the stability of her spine.
We are advised that the Trust recognises that caring for patients in the ED, particularly
those with dementia, is far from ideal. The Trust is committed to continuing to work on
patient flow initiatives which include supporting safe and timely discharges from the
wards, home treatment via virtual wards and Same Day Care to improve the flow of
patients throughout the Trust and reduce the time that patients spend in the ED once
a decision to admit has been made.
Review by the Geriatric Team
The Trust has advised NHS England that their geriatric team does not currently
provide a direct in‑reach service into the ED. However, they do have a dedicated frailty
team and are actively developing this service further. As part of this work, they are
creating a dedicated frailty area within their Same Day Emergency Care unit to offer a
more suitable environment for this patient group.
They are also focusing on ensuring that, from the moment patients arrive in the ED,
their frailty score is used to guide placement and prioritisation. Their aim is to minimise
the amount of time that frail and vulnerable patients spend in the ED and ensure they
receive timely, appropriate care in the most suitable setting.
I would also like to provide further assurances on the national NHS England work
taking place around the Reports to Prevent Future Deaths. All reports received are
discussed by the Regulation 28 Working Group, comprising Regional Medical
Directors, and other clinical and quality colleagues from across the regions. This
ensures that key learnings and insights around events, such as the sad death of Lina,
are shared across the NHS at both a national and regional level and helps us to pay
close attention to any emerging trends that may require further review and action.
Thank you for bringing these important patient safety issues to my attention and please
do not hesitate to contact me should you need any further information.
Yours sincerely,
National Medical Director
NHS England
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