Susan Samson

Executive Corridor 
Darlington Memorial Hospital 
Hollyhurst Road 
Darlington,  
DL3 6HX 

10 April 2026 

Rebecca Sutton,  
Assistant HM Coroner,  
4th Floor Civic Centre, 
Crook, 
County Durham, 
DL15 9ES  

Dear Ms Sutton,  

Re: Susan Samson 

I am writing in response to Regulation 28 Report to Prevent Future Deaths, which you issued 
to County Durham & Darlington NHS Foundation Trust on 23 February 2026. 

We are writing in response to your request for the Trust to take action in relation to concerns 
as detailed below: 

The  Occupational  Therapist  involved  in  the  deceased's  discharge  on  1  May  2025  gave 
evidence that for someone to be assessed as safe to use the stairs on their own, it was not 
sufficient  for  them  to  have  managed  to complete  a  set  of  stairs  without  assistance on  one 
occasion; it was necessary for the person to demonstrate that they could consistently complete 
the  stairs  without  assistance.  The  Occupational  Therapist  stated  that  the  two  successful 
attempts in the Care Home seemed to be enough to achieve consistency and indicated that if 
similar circumstances arose today the patient would still be discharged home at the end of the 
six-week rehabilitation period.  

I found as a fact that prior to the deceased's discharge on 1 May 2025 the deceased had not 
demonstrated that she was able to consistently complete a flight of stairs without assistance. 

 I am concerned by the evidence that if similar circumstances arose today the patient would 
still be discharged. I am concerned that there may be occasions in the future that patients will 
be discharged before they are able to consistently complete a flight of stairs and that, as a 
result, a death may occur. 

The Trust would like to offer its sincere condolences to Ms Samson’s family for their loss. We 
take very seriously the concerns which you have raised and have provided a response below.  

 
 
 
 
 
 
 
 
 
 
 
 
 
 OT stated it was not sufficient to complete set of stairs independently on one occasion, 
necessary to demonstrate consistency. OT stated that the 2 successful attempts in the 
care home seemed enough to demonstrate consistency.  

It is not always necessary to repeat a stair assessment. The decision should be guided by the 
clinician’s  professional  judgement  and  the  patient’s  individual  risk  profile.  If  a  patient  has 
previously  completed  a  stair  assessment  safely  and  no  additional  risk  factors  are  present, 
repetition  is  unlikely  to  be  required.  However,  for  individuals  with  identified risks  such  as  a 
history of falls, reduced strength or balance, or frailty, repeating the assessment can provide 
valuable reassurance by demonstrating consistency and safety over time. 

Ms Samson was assessed in the care home setting on ten occasions and on one occasion in 
her  own  home  and  was  assessed  as  being  able  to  manage  the  stairs  safely.  The 
documentation from the discharge visit  states that Ms Samson managed the steps into the 
house with supervision and managed a sit to stand from the armchair and got up and down 
the  stairs  independently  using  the  banister  and  her  stick.  It  is  documented  that  she  was 
hesitant on the curve at the top of the stairs on way up but had no hesitation on the way down. 

However,  the  Trust  acknowledges  that  the  clarity  around  the  description of  the  supervisory 
role of the therapy staff was unclear and subjective in some of the documentation. 

The Coroner found as a fact that prior to the deceased's discharge on 1 May 2025 the 
deceased had not demonstrated that she was able to consistently complete a flight of 
stairs without assistance. 

The  documentation  relating  to  the  stair  attempts  undertaken  prior  to  discharge  from  the 
intermediate care setting does not clearly confirm that the patient completed the stairs without 
assistance and lacks sufficient objective assessment and clinical analysis. The Trust requires 
the use of the recognised SOAP note structure (Subjective, Objective, Assessment and Plan) 
when recording assessments, which was completed, however the use of the term supervision 
should have been more clearly defined. 

It is noted that a commode for downstairs use was offered but declined by the Ms Samson. 
The provision of such equipment could have reduced the risk of falls by limiting the number of 
required  stair  transfers  each  day  and  minimising  the  likelihood  of  the  individual  rushing  to 
access  toilet  facilities.  However,  neither  the  recommendation  for  the  commode  nor  the 
discussion regarding the risks for not having one were documented.  

In response, the Trust will ensure that SOAP note training is delivered and completed within 
the  next  six  weeks  for  all  Community  Physiotherapy,  Occupational  Therapy,  and  Assistant 
staff, and within four months for all other Physiotherapy and Occupational Therapy staff. In 
addition, the existing record-keeping audit, which provides assurance regarding compliance 
with  required  standards  for  SOAP  documentation  will  continue  to  be  used  to  monitor 
adherence and identify any areas requiring further improvement. 

 
 
 
 
 
 
 
 
 
 
 Concern there may be occasions in the future that patients will be discharged before 
they are able to consistently complete a flight of stairs.  

Ms Samson  was  identified  as  being  at  an  increased  risk  of  falls,  with  several  contributing 
factors  including  frailty  and  a  documented  history  of  previous  falls.  However,  there  is 
insufficient  documentation  regarding  her  understanding  of  these  risks  and  her  expressed 
preferences around discharge.  Although elements of falls risk and mitigation are recorded, 
this information is not consolidated within a single, clearly identifiable document in the current 
patient record. 

The  incorporation  of  a  validated  home-hazard  assessment  tool,  such  as  the  HomeFAST 
(Home Falls Accident Screening Tool), would strengthen the assessment process. This tool 
specifically  evaluates  environmental  risks,  including  stairways  and  steps  and  prompts  the 
clinician  to  develop  a  structured  action  plan,  thereby  supporting  more  comprehensive 
documentation and risk management. 

In response to this incident, the Trust will undertake a review of the current documentation 
and the electronic record template to identify any required amendment and include a validated 
home hazard assessment tool. 

Conclusion 

We trust that the responses detailed in this letter are sufficient to address the concerns you 
have highlighted. However, please feel free to contact us if you need any additional information 
or have further queries. 

Yours sincerely 

Interim Chief Nurse   

Interim Executive Medical Director  

cc.  

 CEO  
 Associate Director of Nursing, Patient Safety, Experience and CNIO

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H.M. Coroners Office 
P.O. Box 274 
Stanley 
County Durham 
DH8 1HG 

CHIEF EXECUTIVE’S OFFICE 
Town Hall, Darlington DL1 5QT 

27th April 2026 

Dear Sir 

Response to Prevention of Future Deaths Report 

1.  Coroner and Case Details 

Coroner: Rebecca Sutton, Senior Coroner/Assistant Coroner for the coroner area of County 
Durham and Darlington 

Deceased: Susan Elizabeth SAMSON (DOB 10th April 1947) 

Date of Death: 7th May 2025 

Inquest Conclusion: Narrative conclusion [On 7 May 2025 at her home address in Darlington, 
the deceased died due to an accidental fall down the stairs. The death was caused by an 
accident, which was contributed to by an unsafe discharge home from a rehabilitation 
placement] 

Date Prevention of Future Deaths Report Issued: 2nd March 2026 

2.  Organisation Responding 

Organisation Name: Darlington Borough Council 

Address: Darlington Borough Council, Town Hall, Feethams, Darlington, DL1 5QT 

Relevant Service: The Chief Executive 

3.  Summary of Coroner’s Concerns 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
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The Prevention of Future Deaths Report identified the following matters of concern: 
1. On 18 March 2025 (via an email timed at 16:19) a request was made by staff at Sedgefield 
Community Hospital to Darlington Borough Council (who were the landlord of the property 
where the deceased lived) to fit a second banister rail in the deceased’s home.  

2. On 10 April 2025 a further request, by an Occupational Therapist working at the Rydal Care 
Home, was made to Darlington Borough Council to fit a second banister rail in the deceased’s 
home.  

3. An appointment was made to fit the second banister in the deceased’s home on 6 May 2025.  

4. For reasons unknown the appointment was changed from 6 May 2025 to 9 May 2025.  

I am concerned by the length of time between the requests for a second banister and the first 
appointment arranged to fit a second banister.  

I am concerned that, if similar circumstances arose today, or in the future, a Darlington Borough Council 
tenant could be exposed to a potentially avoidable risk of death while awaiting the installation of a 
second banister. 

4.  Action Taken or Proposed in Response to the Coroner’s Concerns 

The Council takes the coroner’s concerns extremely seriously. The following actions have been 
taken and/or are planned to address the concern: 

Concern: Delay in responding to requests for minor works/adaptations at council owned 
property 
The Council has in place a process for dealing with any works/adaptations to Council owned 
properties. There is a guide for council tenants. This process is underpinned by a referral form 
which is to be sent to a manned email inbox for all proposed works.  

It is anticipated that works/adaptations such as those required at Susan Samson’s property 
would usually be completed within 4 weeks. However, wherever possible works/adaptations 
will be completed within a timescale suitable to all and dependent upon any specific 
circumstances.  

In respect of the observation/concern of the Coroner ‘For reasons unknown the appointment 
was changed from 6 May 2025 to 9 May 2025’. The timeline for the works is as set out in the 
statement and exhibits of Claire Gardner-Queen dated 26th February 2026. Unfortunately, the 
Council has not had sight of the email from Sedgefield Community Hospital which was 
purported to have been sent on 18th March 2025 and we are unable to ascertain whether the 
email was sent to the correct email address and whether it contained the referral form as 
required. Email correspondence from the OT from CDDFT indicates that she first made the 
referral for the second banister on 10th April 2025 and her referral form omitted the date on 
when Susan Samson would be fit for discharge. The OT had not received a response to that 
referral, and she contacted an officer of the Council on 28th April 2025 in respect of that 
referral. The OT advised that there was no one home at the property and gave details as to 
when Susan Samson was planned on being discharged home, this was planned for 1st May 
2025. The works/adaptations were unable to be carried out prior to Susan Samson’s discharge 
home as there was no one at the property to permit access. Following communication between 

 
 
 
 
 
 
 
 
 
 
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a Council officer and the OT the works/adaptations which were originally scheduled for 14th 
May 2025 were brought forward to 6th May 2025 and the OT was advised of this date. The 
Council can confirm that the works were scheduled to be undertaken on 6th May 2025 and an 
attempt to install the second banister and grabrails was made on that day, but Susan Samson 
refused access to her property advising it was not convenient for the banister to be installed. 
As Susan Samson was a capacitated adult, she was within her rights to refuse access, and the 
Council was unable to lawfully enter and carry out the works in the absence of her consent. 

The Council has reviewed the guide for tenants and are satisfied that there are no changes 
required to this document. 

The referral form and email inbox for receipt of such referral forms remain appropriate, 
however, the Council intends to raise awareness of the referral process to ensure that all 
referrals are dealt with in a timely manner and that any queries in relation to the referral form 
are raised at the earliest opportunity to avoid any delay.  

This case will be used as part of that awareness raising to ensure there is appropriate learning. 

Random sampling audits will be carried out of the referrals. Should the content of the referrals 
be of concern then a review of that form will be considered and reissued. 

5.  How These Actions Will Reduce the Risk of Future Deaths 

The action outlined above aims to strengthen and raise awareness of the process for 
works/adaptations to be completed in respect of council owned properties. This awareness will 
be raised both internally and with external stakeholders, in particular health colleagues. 

It is anticipated that such awareness will improve the level of detail contained within referrals 
and communications and that such measures will reduce the likelihood of any repeat cases of 
individuals being discharged home without appropriate work/adaptations being carried out 
prior to or shortly after a discharge back home, thereby reducing the risk of potentially 
avoidable deaths in similar circumstances. 

6.  Ongoing Monitoring and Review 

Progress against this action will be reviewed by the Council, and any deficiencies will be 
addressed promptly. Learning from this case will also be shared through briefings within 
relevant departments [Housing, Adult and Childrens Social Care]. 

7.  Declaration 

I confirm that the information provided in this response is accurate to the best of my 
knowledge and that the actions described have been, or will be, implemented as stated. 
Name: Rose Rouse 
Job Title: Chief Executive   
Organisation: Darlington Borough Council 
Date: 27 April 2026 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
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Should the Council be able to assist any further please do not hesitate to contact myself where 
I will endeavour to assist wherever possible. 

Yours sincerely 

Chief Executive