Prevention of Future Deaths reports · 2025
Regulation 28 report to prevent future deaths, reference 2025-0634, written 17 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 | 17 Dec 2025 |
|---|---|
| Reference | 2025-0634 |
| Deceased | Debapriya Ghosh and David Ward |
| Coroner | Fiona Wilcox |
| Coroner area | London Inner (West) |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
REGULATION 28: REPORT TO PREVENT FUTURE DEATHS REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: Secretary of State for Health and Social Care, 39, Victoria Street, London. SW1H 0EU CORONER 1 I am Dr Fiona J Wilcox, HM Senior Coroner, for the Coroner Area of Inner West London 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. 3 INVESTIGATION and INQUEST On 2nd December 2025 evidence was heard in two inquests touching the deaths of : 1. Dr Debapriya Ghosh, who had died at St George's Hospital on 11th February 2024 aged 83 years. Medical Cause of Death la Subdural haemorrhage lb Traumatic Head Injury II lschaemic heart disease. How, when and where the deceased came by his death. Dr Ghosh was admitted to St George's Hospital on the morning of 9th February 2024. The A&E department was exceptionally busy. He was initially cared for in the corridor and did not transfer to a cubicle until early evening. He was frail, suffering with delirium, electrolyte imbalance, infection and a type II myocardial infarction. He was not risk assessed by the nursing staff until almost midnight. In the early hours of the morning of 10/2/2024 his delirium and agitation increased such that medical advice was sought. However his nursing risk was not reassessed, and he should have been escalated for 1:1 care. At around 08:30 he had an unwitnessed fall and sustained a significant head injury that directly led to his death at 16:27 11/2/2024. If he had been allocated appropriate nursing supervision his death would have been avoided. Conclusion of the coroner as to the death: Accidental fall contributed to by a failure to provide appropriate nursing _ supervision. 2. Mr David Albert Ward who had died at St Goerges Hospital on 10th February 2024 aged 76 years. Medical cause of death: 1 a Subdural Haemorrhage 1 b Traumatic Head Injury II Non-Hodgkin Lymphoma How, when and where the deceased came by his death Mr Ward was admitted to St George's Hospital with frailty, confusion and likely infection on 7/2 /2024. On 12/1/2024 he had emergency surgery in Poole for colonic lymphoma. Due in part to acuity in A&E he received no nursing risk assessments and following his daughter leaving at approximately 02:30 8/2/2024 received no significant nursing care. He was found kneeling by his bedside having suffered a head injury which led to and caused his death on 10/2/2024 at 13:45. His nursing risk was such that he should have received enhanced care and if he had done so the fall and his death would have been avoided. Conclusion of the coroner as to the death. Accident contributed to by neglect. 4 Evidence Relevant to the Matters of Concern: Extensive evidence was taken from the families, nurses, doctors and pathologists. In each case it was clear that due to patient acuity there was insufficient resource in terms of cubicles and bed spaces and insufficient nursing staff to manage the demand in the department. In each case frail elderly men were left to wait for very many hours being cared for by their families, rather than supported by nurses and treated in proper bed spaces. When their families left during the night, they both fell as they were unsupervised, sustaining injuries that led to their deaths. Since the deaths St Georges Hospital has put in place systems to try and allocate more nurses to A&E, divert frail patients to an elderly care unit, train and audit on risk assessments and make available health care assistants to help care and monitor patients who need 1:1 care amongst other matters. However evidence was taken during the inquest of Mr Ward that despite all these measures many shifts in A&E are still exceptionally busy and feel little different to how they were back in Feb 2024. This was clearly causing distress to the staff attempting to manage impossible situations where demand clearly exceeds available resource in terms of staff and facilities. 5 Matters of Concern 1. That St George's Hospital and other hospital A&E departments have insufficient staff to manage demand during busy periods such that nursing risk cannot be managed without relying on families. 2. That at work stress on A&E staff due to staff and resource shortages may cause them to leave the profession exacerbating shortages of experienced staff and thus increase risks in A&E. 3. That local hospitals such as St George's have implemented multiple actions within their power to attempt to manage demand and risk, but these have been insufficient such that risk remains, and so central consideration should be given to the issues. 4. That it is unsafe for families to leave their loved ones unsupervised in overcrowded A&E departments. 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you [AND/OR your organisation] have the power to take such action. It is for each addressee to respond to matters relevant to them. 7 YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report. 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 Interested Persons: Interim Group Chief Executive Officer, St George's University Hospitals, NHS Foundation Trust, Blackshaw Road, London. SW17 OQT , 57, Queen's Road, Wimbledon, SW19 8NP , 30, Gap Road, London. SW19 8JG 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 17th December 2025 Dr Fiona J Wilcox HM Senior Coroner Inner West London Westminster Coroner's Court 65, Horseferry Road London SW1P 2ED Inner West London Coroner's Court, 33, Tachbrook Street, London. SIAI1V 2JR Telephone:0207 641 8789.
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.
Minister of State for Health (Secondary Care) 39 Victoria Street London SW1H 0EU 11 March 2026 HM Senior Coroner Dr Fiona J Wilcox Inner West London Coroner’s Court 33 Tachbrook Street London SW1V 2JR Dear Dr Wilcox, Thank you for the Regulation 28 report of 17 December 2025 sent to the Secretary of State about the deaths of Dr Debapriya Ghosh and Mr David Albert Ward. 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 Dr Ghosh and Mr Ward’s deaths, 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 these matters. The report raises concerns over insufficient staffing within A&E departments, workforce stress, insufficiency managing demand and risk, and patient safety. In preparing this response, my officials have made enquiries with NHS England to ensure we adequately address your concerns. I understand a copy of your report has also been sent to St George’s University Hospitals NHS Foundation Trust. I understand that St George’s University Hospital NHS Foundation Trust conducted a Serious Incident investigation into the deaths of Dr Ghosh and Mr Ward. Subsequently the Trust implemented actions to strengthen nursing oversight and mitigate risk during periods of high demand. It has reinforced completion of cubicle and falls risk assessments, supported by re-education of Nurse in charge and daily monitoring to ensure timely documentation and escalation. Matron assurance rounds have been introduced to review compliance within two hours of cubicle allocation, with follow up where assessments are incomplete. Audit processes have been strengthened, with compliance monitored through the Trust’s RATE system. The Trust has also established daily safe staffing meetings, enhanced safety huddles to include falls risk and enhanced care needs and introduced additional Healthcare Assistant shifts to support Majors areas. Staffing concerns are also now escalated and mitigated through divisional oversight, with redeployment when required. I recognise concerns about stress linked to staffing pressures. Trusts must support staff wellbeing, while NHS England’s Long Term Workforce Plan and retention programme aim to improve staff experience and strengthen planning and leadership. I recognise the concern that local actions may be insufficient where emergency department crowding persists and this may impact patient safety. ED crowding is a complex, system wide issue requiring coordinated action across providers and partners to improve patient flow and mitigate risk of harm. The Government recognises the challenges facing the health service and are serious about tackling them. The Government is 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. We recognise to achieve this we will need to make improvements to patient flow through the whole system, and the plan outlines a set of priority actions to support systems to maximise patient flow, including: • • • • • 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. I hope this response is helpful. Thank you for bringing these concerns to my attention. Kind regards, MINISTER OF STATE FOR HEALTH
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