Josh Tarrant (1)

Frimley Park Hospital  
Portsmouth Road  
Frimley  
Camberley  
GU24 7UJ  

 23   May 2026  

PRIVATE AND CONFIDENTIAL 

Mr R Simpson Assistant coroner 
Coroners’ office  
Reading Town hall 
Blagrave Street 
Reading RG1 1QH  

Dear Sir 

Trust Response to Regulation 28 Report for the Prevention of Future Deaths. 

 RE: Inquest touching the death of Mr John Tarrant. 

The coroner’s concerns are replicated in bold below: 

1. Falls risk assessments. 
Only 2 falls risk assessments were carried out after Mr Tarrant arrived at the 
hospital. Both falls risk assessments used the Hester Davis scoring system, but 
both had carried out based on incorrect data. The falls risk assessments both 
resulted in a low-risk outcome which was not correct. Mr Tarrant should have been 
graded as a moderate risk even prior to his fall. Some of the data entered into the 
risk assessment tool was objectively wrong. For example, in the risk assessment 
carried out hours after his fall it stated that he had not fallen before. 

I heard that the Trust did not have a way of assessing and auditing the accuracy of 
these risk assessments. Whilst I found that the errors in this inquest did not 
contribute to Mr Tarrant’s death incorrect risk assessments can lead to inadequate 
falls mitigation measures being put in place and incorrect information being 
provided to staff. 

 
 
 
 
 
 
 
 
 
 
 
 
 A falls risk assessment was performed on attendance in the Emergency Department 
and following Mr Tarrant’s inpatient fall. For Mr Tarrant’s admission, these 2 falls risk 
assessments were all that was required. (Patients should be risk assessed for falls on 
admission to clinical areas, after a fall, or when their clinical picture changes). 
However, the Hester Davis scoring system which was in use at the time was calculated 
inaccurately by staff. Prior to Mr Tarrant’s inquest, the Trust had already acknowledged 
that the Hester Davis falls risk assessment was not intuitive for staff to use and, scoring 
mistakes were noted. Therefore, the Trust re-designed a new falls risk assessment 
which was launched on the electronic patient record system. The new falls risk 
assessment was in progress at the time of Mr Tarrant’s fall, and the Trust had been 
working on this for >12 months.  

The revised falls risk assessment is based on national guidance and is much easier for 
staff to use. The new risk assessment now grades patients as either “at risk”, or “not at 
risk” of falls rather than using the previous grading score of ‘low’ ‘moderate’ or ‘high’ 
risk. This new assessment significantly reduces the likelihood of incorrectly scoring a 
patient at risk. The revised risk assessment has been in use for the entire Trust since 
September 2025.   We apologise if this initiative was not communicated to the coroner 
prior to or during the inquest hearing on 30 March 2026.  

For further context, whilst  in Mr Tarrant’s case the risk score was incorrectly deemed to 
be ‘low’ rather than ‘moderate’ in accordance with the scoring system at the time, even 
if the correct risk score of “moderate”  had been correctly identified, the falls mitigating 
measures in place would not have changed. For example. and a green wristband used 
as a quick visual prompt for being at risk of falls. At the time of the fall, Mr Tarrant was in 
the bathroom seated on the toilet. The HCA attended to check on Mr Tarrant. He 
reported he did not require any assistance. He had non-slip footwear in place; the floor 
was dry and there were no environmental hazards. The HCA advised she would wait 
outside the door in case he required assistance and to allow him privacy. Shortly after 
she heard a noise and found him on the floor. Unfortunately, Mr Tarrant tried to get up 
from the toilet alone and fell.  

The Trust has a Harm Free Care Audit Programme which aims to promote high 
standards of nursing care. The Harm Free Care Audit Programme was introduced in July 
2025 as a monthly audit, to be completed by senior ward leaders, and encompasses 
key aspects of nursing care including falls prevention. Twenty-five per cent of the 
patients in a clinical area are audited. This audit tool is one of several methods 
available to monitor compliance with nursing care standards, including spot checks on 
the ward and compliance monitoring by senior ward leaders. 

The target of compliance for this audit is 90%. Whilst the time limited initial assessment 
scores (to risk assess a patient within 6 hours of being admitted to a ward) do not 
reflect reaching the target, the reassessment compliance indicates that falls and 
bedrail assessments are being completed but may be documented more than 6 hours 
post arrival on the ward. The reassessment figures are consistently above target. 

 
 
 
 
 
 
 The Trust has a dedicated quality improvement workstream to reducing the number of 
inpatient falls and this is led by one of our senior nurses. This workstream has been in 
place for the last 2 years. Nationally, the Royal College of Physicians state that 
approximately 20% of inpatient falls are preventable. Over the last financial year, the 
Trust has reduced the incidence of inpatient falls by 12% and the incidence of inpatient 
falls is currently at the lowest number the Trust has had for the last 5 years. It was 
unfortunate this was not communicated to the coroner as this would have provided a 
clearer view of initiatives undertaken in the Trust. 

As part of the quality improvement workstream, the Trust has a multidisciplinary Falls 
Steering Group to oversee delivery, ensuring the implementation of evidence-based 
prevention strategies and sustained organisational focus.  In the last financial year falls 
prevention information has been updated to better support patients and families in 
understanding risks and contributing to prevention, via a leaflet. These are available in 
clinical areas.  

Prior to the inquest, two safety campaigns had already been initiated, including the 
relaunch of ‘Stay in the Bay’ and ‘Call Don’t Fall’. Both have now been reinforced across 
all sites. ‘Call Don’t Fall’ posters have been displayed in clinical areas, including all 
patient bathrooms in the organisation. ‘Stay in the Bay’ lanyards have been provided to 
all clinical areas for staff to use, to empower staff to decline leaving the bay / specific 
patient if providing enhanced / 1:1 care.  

Targeted falls prevention training has been delivered across Heatherwood Hospital, 
Heathlands and Farnham Rehabilitation settings, alongside the introduction of a ‘Falls 
Champion’ programme to embed best practice at ward level. Training has been 
delivered to the fall's champions, and this will occur as a minimum of every 3 months.  

The Trust has trialled new hospital beds with integrated falls alarms and the Trust has 
invested in some of these beds. Falls data analysis has been used to identify high-risk 
clinical areas that would benefit most from these beds and other interventions. 

Orthostatic blood pressure guidance has been standardised and embedded within 
ward observation processes to improve identification and management of falls risk 
factors. Easy to follow laminated guides on the correct assessment of lying and 
standing blood pressures have been attached to all observation machines in clinical 
areas. 

A simplified multidisciplinary team review form has been developed to support frontline 
teams in undertaking timely, structured post-falls reviews and identifying learning. This 
is also available on our incident reporting system, ‘In-Phase’. The Trust monitors the 
number of inpatient falls and in which clinical areas these occur and the data is shared 
with the senior leaders of the clinical areas every month. 

The Trust is also in the process of implementing a national campaign for falls 
prevention, the ‘Think Yellow’ campaign. This is planned to strengthen staff and 

 
 
 
 
 
 
 
 
 patient/visitor awareness and promote consistent falls prevention behaviours across 
all sites. Currently this has been piloted in both Emergency Departments. The initiative 
uses a ‘think yellow’ pack which consists of a yellow patient blanket, wristband and 
non-slip socks to quickly help staff identify the patients who are at risk of falls. The plan 
is that this will be rolled out to the rest of the organisation by the end of July 2026. 

The Trust has also identified advanced falls monitoring solutions are available. A trial of 
new falls prevention equipment (sensors for beds, chairs and toilets) is currently 
planned for a Care of the Elderly ward at Frimley Park Hospital, with a planned trial to 
also include Farnham Community Hospital – rehabilitation ward with single en-suite 
rooms. If the trial is successful, a phased rollout of the equipment will occur across the 
Trust. 

2. Anti coagulation risk awareness. 
The doctor who reviewed the CT results and neurosurgery advice after Mr Tarrant 
fell did not appreciate the urgency of the situation. I found in this inquest that due 
to timing issues this was not likely to have affected the outcome for Mr Tarrant. 

I heard from the consultant witness that the risks of anticoagulation are poorly 
understood. The post falls proforma was reviewed in court and, whilst it asked 
whether the patient was on anticoagulation medication, it did not provide a prompt 
about this during the post fall medical planning section. This led to a concern that 
the importance of considering administering an anticoagulation reversal 
medication and the urgency of such a need may be underappreciated. 

Mr Tarrant was correctly anticoagulated with warfarin (INR target 3-4) for a prosthetic 
aortic valve. 

On admission, his Warfarin was correctly held when he presented unwell as his INR 
over 6 and therefore outside the therapeutic range. INR frequently becomes unstable 
when patients are unwell. A single dose of clarithromycin (antibiotic) was administered, 
which can interact with warfarin and may have contributed to the subsequent high 
INRs. However, this potential interaction was recognised during the post-take ward 
round, and the antibiotic was changed to doxycycline. Despite the high INR level, there 
was no evidence of active bleeding and standard practice would be to allow the INR to 
reduce naturally given the critical indication for anticoagulation in Mr Tarrant’s case. 

When Mr Tarrant fell and the CT scan showed a small subdural bleed, as is standard 
practise, our tertiary neuro-surgical centre was contacted. In addition to advice on 
neurosurgical management their advice with regard to the anticoagulation was to 
contact Frimley haematology for consideration regarding reversal of anticoagulation. 
Unfortunately, haematology was not contacted.  Vitamin K was administered to Mr 
Tarrant , however had the on-call haematology consultant been called, they would have 
advised correction with Beriplex (PCC concentrate) and Vitamin K.as Beriplex has a 
faster action than Vitamin K. Whilst the risk of stroke or valve obstruction would have 

 
 
 
 
 
 
 
 been temporarily increased by reversal, extension of the subdural bleed was  at the 
time the greater risk. 

Our consultant haematologist on-call service is available 24/7, 365 days of the year, 
and it is very common for the consultant haematologist on-call to be contacted for 
advice in just this scenario. The Trust does not accept that the risks of anticoagulation 
are ‘poorly understood’, which was evidence provided to the coroner during the 
hearing. One of the Trust’s Consultant Haematologists confirms that in her experience 
clinicians are very aware of the risks of anticoagulation together with the risks of 
inappropriately stopping these agents.  In other words, it was probable that the 
evidence regarding a ‘poor understanding’ was related to the risk benefit balance which 
is what can make such decisions difficult. There is good understanding of the risks in 
the case of a bleeding anticoagulated patient and clear understanding of where to 
obtain expert advice.  

The availability of expert Consultant Haematologist advice 24/7, 365 days of the year is 
also strongly reiterated at the resident doctor’s induction training to the Trust, and the 
clear evidence is this is regularly accessed.  

In addition, the Trust has long-standing published guidance on reversal of all 
anticoagulant agents, and these are available on the Trust intranet, and this is easily 
accessible on individual’s mobile devices. The guideline has been in place since 2021. 
At the time of Mr Tarrant’s incident, the Trust guidance was in place and available for all 
to access.  The chief medical officer has monthly safety briefings in person to all 
resident doctors. Going forward, this briefing will be aiming to increase awareness to all 
the importance in escalating to senior level in such circumstances where there is a risk 
of continuing anticoagulation and/or where reversal is a consideration. 

Trust guideline - Emergency Reversal of Oral Anticoagulants v2 

Yours sincerely 

Chief Executive Officer 

In partnership with the Ministry of Defence  
Frimley Health incorporates Frimley Park Hospital, Heatherwood Hospital and Wexham Park

Mr Scott Matthewson 
Assistant Coroner for Mid Kent and Medway 
Kent and Medway Coroners Service  
Oakwood House 
Oakwood Park 
Maidstone  
Kent  
ME16 8AE 

Medical Director for Mental Health 
and Neurodiversity  
NHS England  
Wellington House 
133-155 Waterloo Road  
London 
SE1 8UG 

20th April 2026 

Dear Coroner, 

Re: Regulation 28 Report to Prevent Future Deaths – Josh Yemi Tarrant who 
died on 1 November 2023.  

Thank  you  for  your  Report  to  Prevent  Future  Deaths  (hereafter  “Report”)  dated  9 
February 2026 concerning the death of John Yemi Tarrant on 1 November 2023. In 
advance of responding to the specific concerns raised in your Report, I would like to 
express my deep condolences to Mr Tarrant’s family and loved ones. NHS England is 
keen  to  assure  the  family  and  yourself  that  the  concerns  raised  about  Mr  Tarrant’s 
care have been listened to and reflected upon.   

I am grateful for the further time granted to respond to your Report, and I apologise for 
any anguish this delay may have caused to Mr Tarrant’s family and friends. I realise 
that responses to Coroners’ Reports can form part of the important process of family 
and  friends  coming  to  terms  with  what  has  happened  to  their  loved  ones,  and  I 
appreciate this will have been an incredibly difficult time for them. 

Your report raised concerns around the lack of training provided to prison healthcare 
staff in relation to Acute Behavioural Disturbance (ABD) (despite the clear advice of 
Prison Service Order 1600 (2005)) and if prison nurses remain unaware of ABD and 
the need to treat it as a medical emergency, then further deaths are likely in future.  

Background on Acute Behavioural Disturbance 

The term ‘Acute Behavioural Disturbance' (ABD) is not a formal diagnosis within the 
International Classification of Diseases (ICD-11), which is the global diagnostic tool 
used in the NHS. ABD is generally used to describe behaviours linked with extreme 
agitation or distress, which may indicate a potentially life-threatening physical health 
emergency.  NHS  England  recognises  the  importance  of  ensuring  that  individuals 
presenting in extreme distress receive timely, safe and effective care. ABD is not a 
specific  condition  with  a  set  of  defined  symptoms.  It  is  not  common  and  it  is  very 
difficult  to  identify  the  difference  between  agitation,  antisocial  behaviour,  deliberate 
violent behaviour and ABD. There is no reliable way to determine mild or severe ABD 
in  the  pre-hospital  setting  nor  over  the  phone  during  a  triage  process.  ABD  is  a 

                                                                                                                       
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 complex but known clinical presentation, and the Royal College of Psychiatrists has 
published guidelines on managing ABD. 

We have considered your concerns to inform our learning and we have consulted with 
,  Consultant  Forensic  Psychiatrist  and  member  of  NHS  England 

Health and Justice Clinical Reference Group.  

Given the rarity and complexity of ABD and the operational realities of prisons, it is not 
reasonable  to  expect  prison  healthcare  staff  to  diagnose  ABD  reliably.  The  critical 
safety issue is recognition of severe agitation accompanied by physiological red flags 
and escalation as a medical emergency.  

In 2025 NHS England developed a framework for healthcare roles and responsibilities 
for  planned  and  unplanned  use  of  force  in  adult  prisons  and  immigration  removal 
centres  which  was  communicated  to  all  healthcare  providers  in  August  2025.  This 
framework  supports  HMPPS  and  Home  Office  policy  documents  and  makes  clear 
healthcare requirement to attend all planned, and where possible, unplanned use of 
force incidents.  

This framework strengthens the expectations of healthcare staff and provides explicit 
guidance  around  warning  signs  of  ABD.  This  revised  framework  offers  clearer 
boundaries and ensures that all staff involved in use of force events share a consistent 
approach to managing risk, including the risk of ABD. Use of force is the terminology 
used by HMPPS and Home Office and includes the use of physical, mechanical and 
chemical restraint.  

We will be sharing the details of this report with all prison and Immigration Removal 
Centre healthcare providers with an action to ensure all establishments have a clear 
red flag criteria and emergency escalation pathway within existing healthcare training 
structures and operation briefings. This should include a focus on early recognition of 
deterioration,  prompt  ambulance  activation  where  indicated,  minimising  restraint 
duration  and  maintaining  continuous  observation  until  handover,  with  routine 
governance review of such incidents.  

In addition, the findings, information and any learning from this case will be tabled at 
a  future  NHS  England  Health  and  Justice  Delivery  Oversight  Group  (HJDOG).  The 
HJDOG is the senior leadership forum, which holds responsibility for the oversight of 
delivery and continuous improvement in Health and Justice commissioned services, 
through  both  national  and  regional  teams.  All  health  and  justice  related  Reports  to 
Prevent Future Deaths are shared and discussed at the HJDOG, and assurance is 
sought from regions where learning and action is identified.  

Regional Response  

South  East  Regional  Colleagues  have  shared  reports  around  the  Trust’s  PSII  and 
PPOs independent review. South East Regional Colleagues have advised that both 
sets of reports identify that clinical staff should receive training in managing violence, 
aggression and mental health crises, as well as the fact some actions taken by staff , 
particularly around restraint, were not with current guidance and policy. Neither report 
shared mentions ABD or ‘Excited Delirium’, suggesting that Mr Tarrant’s presentation 

 
 
 
 
 
 
 
 
 was directly related to cocaine use and exacerbated by a heart condition, which the 
prison staff had no knowledge of at the time, as it was only detected postmortem.  

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 Mr 
Tarrant, 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,  

Medical Director for Mental Health and Neurodiversity  

NHS England