Dennis Price

5 March 2026 

STRICTLY CONFIDENTIAL – ADDRESSEE ONLY 
Ms N J Mundy 
Senior Coroner for South Yorkshire (East District) 
Coroner’s Court and Office 
Crown Court 
College Road 
Doncaster DN1 3HS 

Dear Ms Mundy 

Dennis Keith Price (deceased) 

I write to you with respect to the Regulations 28 Report issued on the 20 January 2026 to 
Chief Executive of Doncaster & Bassetlaw Teaching Hospitals NHS Foundation Trust following the Inquest 
into the death of Dennis Keith Price concluded on the 12 January 2026.   

The report was received by the Chief Executive’s office and forwarded to me in order to provide a response. 

I have been assisted in constructing this response by Dr Youssef Sorour, Associate Medical Director for Clinical 
Safety and Marie Hardacre, Associate Chief Nurse for Patient Safety & Quality. 

I would respond to the matters of concern referred to within the PFDR as follows: 

1.  Failure to properly complete the inpatient post fall review 

A Trust Patient Falls Prevention and Management Policy (PAT/PS 11) is in place and is readily accessible via 
the Trust intranet. This policy provides clear guidance for healthcare professionals on the management of 
inpatient falls, including the requirement for appropriate neurological observations following a fall. Following 
the  tragic  death  of  Mr  Price,  it  has  become  apparent  that,  although  healthcare  professionals  acted  in 
accordance with the policy, the associated documentation—specifically the Inpatient Post-Fall Review—was 
not fully completed. 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 Accurate, timely and comprehensive documentation following an inpatient fall is essential to ensure patient 
safety  and  to  demonstrate  that  appropriate  clinical  assessment  and  ongoing  monitoring  have  been 
undertaken. In particular, the clear and complete recording of post-fall assessments, including neurological 
observations  where  indicated,  is  critical  to  support  early  identification  of  deterioration,  inform  clinical 
decision-making,  and  enable  effective  communication  across  the  multidisciplinary  team.  The  Inpatient 
Post-Fall Review serves as a key clinical record, providing assurance that required assessments have been 
completed  in  line  with  Trust  policy.  The  Trust  recognises  that  failure  to  fully  complete  required 
documentation may undermine these objectives, even where appropriate clinical actions have been taken. 

The Trust recognises that training is fundamental in reinforcing the importance of complete, accurate and 
contemporaneous clinical documentation, and this remains a core component of all education delivered 
by  the  Patient  Safety  Team.    In  addition,  targeted  documentation  training  has  been  delivered  by  the 
Trust’s Solicitor/Legal Manager to Foundation Year 1 doctors on 11 September 2025, and to Preceptorship 
Nurses on 11 and 25 November 2025. This programme of education forms part of an ongoing initiative, 
with  further  lectures  and  seminars  planned  to  ensure  continued  reinforcement  of  documentation 
standards across the organisation. 

2.  No clear plan for frequency of neurological observations and duration of the same and associated lack 

of clear direction from the attending Doctor following a fall 

The Trust acknowledges the concern regarding the absence of consistently documented medical direction 
for the frequency and duration of neurological observations following Mr Price’s fall.  While the Patient Falls 
Prevention and Management Policy (PAT/PS 11) provides guidance on post-fall management, learning has 
identified the need for clearer, explicit documentation by the attending doctor to ensure that neurological 
observation requirements, review arrangements and escalation plans are clearly defined and understood by 
the multidisciplinary team. As part of ongoing improvement, the Trust is reinforcing the expectation that a 
clear,  individualised  post-fall  monitoring  plan  is  documented  following  every  fall,  supported  through 
strengthened  documentation  standards,  targeted  multidisciplinary  training  and  continued  emphasis  on 
completion of the Inpatient Post-Fall Review. 

3.  The efficiency of the Nerve Centre system escalations in that any triggers must be followed up and 

properly completed on the system for the nerve centre system to be fully effective 

The Trust recognises the importance of the Nerve Centre system in supporting timely escalation and clinical 
decision-making  and  acknowledges  the  concern  raised  regarding  the  effectiveness  of  escalations  where 
system triggers are not fully completed. Review of Mr Price’s care identified a documentation gap within 
Nerve Centre, specifically the absence of a recorded name confirming to whom the escalation was made, 
which limited assurance that the escalation process had been completed as intended. For the Nerve Centre 
system  to  function  effectively,  it  is  essential  that  all  triggers  are  acted  upon,  followed  up  and  fully 
documented,  including  clear  identification  of  the  clinician  to  whom  concerns  are  escalated.  As  part  of 
ongoing learning, the  Trust  is reinforcing expectations around the completion of Nerve Centre escalation 
records,  supported  by  targeted  training  and  renewed  emphasis  on  accurate,  contemporaneous 
documentation to strengthen patient safety and system reliability. 

Summary of Actions 

1.  Documentation and Training: 

Targeted multidisciplinary training is being delivered and reinforced to promote accurate, complete and 
contemporaneous  clinical  documentation,  with  particular  emphasis  on  post-fall  documentation  and 

 
 
 
 
 neurological observations. Documentation standards remain a core component of Patient Safety Team 
training, with additional sessions delivered by the Trust’s Solicitor/Legal Manager and further education 
planned on an ongoing basis. 

2.  Post-Fall Medical Direction and Neurological Observations: 

The  Trust  is  reinforcing  the  requirement  that,  following  an  inpatient  fall,  the  attending  doctor  must 
document  a  clear,  individualised  plan  for  neurological  observations,  including  frequency,  duration, 
review  and  escalation  criteria.  This  expectation  is  being  embedded  through  strengthened  post-fall 
documentation standards and targeted multidisciplinary education. 

3.  Nerve Centre Escalations: 

Use of the Nerve Centre system is being reinforced to ensure that all escalation triggers are actioned, 
followed up and fully completed, including clear documentation of the name and role of the clinician to 
whom escalation is made. Targeted training and renewed emphasis on accurate system documentation 
are being implemented to improve reliability, assurance and patient safety. 

Conclusion 

By implementing the proposed recommendations, the Trust has an opportunity to strengthen the quality 
and  consistency  of  clinical  documentation.  Improved  documentation  will  enhance  clarity  of  clinical 
decision-making, support effective multidisciplinary communication and provide greater assurance that care 
is delivered in line with Trust policy. Collectively, these improvements will contribute to safer care delivery 
and, ultimately, to improved patient outcomes. 

I trust this information provides reassurance that learning from Mr Price’s case will lead to improvements in 
pathways and processes, ultimately strengthening patient safety. 

Yours sincerely 

Acting Executive Medical Director 

Cc: 

, Chief Executive 
 Associate Medical Director for Clinical Safety 
 Associate Chief Nurse for Patient Safety & Quality