Urmila Patel

Newham University Hospital 
Glen Road 
London 
E13 8SL 

Dear Mr Irvine, 

Re: Regulation 28 Report to Prevent Future Deaths 

Thank you for your Regulation 28 Report dated 25 February 2026, issued following the inquest into the 
death  of  Mrs  Urmila  Patel.  On  behalf  of  Barts  Health  NHS  Trust,  I  would  like  to  express  our  sincere 
condolences to Mrs Patel’s family and acknowledge the seriousness of the concerns you have raised. 
A detailed internal review has been undertaken to ensure the circumstances identified during the inquest 
are fully understood and that proportionate and sustainable actions are implemented to reduce the risk of 
similar events occurring in the future. 

Following the inquest, the Trust has progressed regulatory referrals for the staff involved, in line with your 
request.  These  are being  managed  in  conjunction with  Workforce and  Professional  Standards  teams to 
ensure they are undertaken in a timely, proportionate, and supportive manner, with learning identified to 
inform  wider  improvement.  In  parallel,  the  circumstances  of  this  case  have  been  reviewed  through 
safeguarding processes, including referral to the relevant local authority and progression for consideration 
of  a  Safeguarding  Adult  Review.  Oversight  of  these  processes  is  maintained  through  Trust  Workforce 
Governance and the Safeguarding Committee. 

Below, I set out our response to each matter of concern and the actions taken. 

1. Falls prevention and care planning 

You  raised  concern  regarding  the  failure  to  complete  an  adequate  falls  risk  assessment  on 
admission and the absence of a documented mobility or falls care plan. 

The  Trust  acknowledges  that  falls  risk  assessment  and  care  planning  for  Mrs  Patel  were  not 
completed  in  line  with  expected  standards.  This  represented  a  missed  opportunity  to  identify  risk 
and implement preventative measures at an early stage. 

Actions taken 

Targeted  education  has  been  delivered  to  nursing  staff,  focusing  on  the  timely  completion  of  falls 
risk  assessments  on  admission,  recognition  of  dynamic  risk,  and  the  importance  of  translating 
assessed  risk  into  clear  and  practical  care  plans.  This  has  been  reinforced  through  ward-based 
teaching, safety huddles, and incorporation into local induction and refresher training. 

Accountability  has  been  strengthened  through  clearer  expectations  of  ward  leadership.  Ward 
managers and  nurses  in  charge  are  now  required  to  review  new  admissions  each  shift  to  confirm 
that  falls  risk  assessments  and  associated  care  plans  have  been  completed,  with  prompt  action 
taken where gaps are identified. 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 A programme of routine audit has been introduced to review both completion and quality of falls risk 
assessments and care plans. Findings are reviewed at ward level and escalated through Divisional 
Governance where required, with actions agreed, tracked, and re-audited. 

Falls  risk  and  mobility  status  are  now  explicitly  discussed  at  shift  handovers  and  safety  huddles, 
supporting  visibility  across  the  multidisciplinary  team  and  consistent  application  of  preventative 
measures. 

Falls  prevention  has  also  been  strengthened  through  a  multidisciplinary  quality  improvement 
programme,  recognising  the  contribution  of  nursing,  medical,  therapy,  and  pharmacy  teams.  This 
includes  initiatives  focused  on  appropriate  footwear,  structured  medication  review  (including 
medicines associated with increased falls risk), and consistent post-fall multidisciplinary review. 
To support assurance, a ward-level falls audit programme commenced on 2 February 2026, with the 
most recent audit completed on 14 April 2026. Early findings demonstrate high compliance with falls 
risk  assessment  (97.2%),  improved  initiation  of  falls  care  plans  (83.3%),  improved  completion  of 
lying and standing blood pressure (78%), and timely medical review following falls. These findings 
are reviewed through ward and divisional governance processes to support sustained improvement. 

Status: Implemented and embedded through education and governance oversight. 

2. Failure to recognise and escalate following a fall and inadequate monitoring 

You  raised  concerns  that  Mrs  Patel’s  fall  on  29  June  2025  was  not  recognised  or  escalated 
appropriately, and that monitoring and supervision were insufficient. 

The  Trust  recognises  that  post-fall  recognition,  supervision,  and  escalation  were  not  sufficiently 
robust and that this contributed to a delay in identifying deterioration risk. 

Actions taken 

A  mandatory  post-fall  care  bundle  and  checklist  has  been  introduced  for  all  inpatient  falls.  This 
ensures that each fall is managed as a clinical event requiring structured assessment and response, 
aligned to the Patient Safety Incident Response Framework. 

The  care  bundle  requires  completion  of  defined  immediate  actions,  including  neurological 
observations,  clear  escalation  triggers,  and  documentation  within  the  clinical  record.  This  is 
supported by standardised documentation prompts to promote consistency. 

To  strengthen  escalation,  a  Red  Flag  Escalation  Standard  Operating  Procedure  has  been 
developed and is being embedded. This provides clear triggers for escalation to medical teams and 
explicitly  includes  concerns  raised  by  patients,  relatives,  or  staff.  This  is  supported  by  the 
implementation  of  Martha’s  Rule,  enabling  families  to  request  urgent  clinical  review  where 
deterioration is suspected. 

Senior  oversight  has  been  enhanced  through  the  introduction  of  an  out-of-hours  falls  review 
protocol,  requiring  the  Duty  Matron  or  Site  Manager  to  review  all  inpatient  falls  within  two  hours, 
providing assurance that appropriate actions and escalation have occurred. 

Monitoring  reliability  has  been  strengthened  through  regular  audit  of  post-fall  neurological 
observations, with findings reviewed through divisional governance structures. 
In addition, multidisciplinary simulation training has been introduced, using scenarios such as 
anticoagulated patients and neurological deterioration, to reinforce recognition of risk, escalation, 
and immediate management. 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 Status: Implemented and monitored through audit, senior clinical oversight, training, and 
governance oversight. 

3. Clinical decision-making following the fall: head injury, CT imaging, and anticoagulation 

You raised concerns regarding the failure to adequately assess the risk of intracranial bleeding, the 
absence of timely CT imaging, and failure to review anticoagulation. 

The Trust accepts that clinical decision-making following the fall did not meet the expected standard, 
particularly given the known risks associated with head injury in anticoagulated patients. 

Actions taken 

A mandatory post-inpatient fall medical review care bundle has been implemented, supported by a 
standardised proforma. This provides a structured framework for clinical assessment and decision-
making following a fall. 

The proforma requires: 

Immediate neurological assessment, including Glasgow Coma Scale and delirium screening  
• 
•  Consideration of intracranial injury and need for urgent CT imaging in line with NICE guidance  
•  Specific prompts relating to anticoagulated patients  
•  Mandatory  review  of  medications,  including  anticoagulation,  with  clear  documentation  of 

decisions  

The  care  bundle  also  requires  review  of  recent  clinical  history  and  investigations  to  identify 
contributory factors and inform management. 

Clear expectations are set regarding escalation to senior decision-makers where there is uncertainty 
or increased clinical risk. 

Learning  from  this  case  has  been  shared  through  medical  and  nursing  governance  forums  and 
reinforced  through  simulation-based  training  focusing  on  deterioration,  imaging  decisions,  and 
anticoagulation safety. 

Status:  Implemented and  embedded  through  mandatory  documentation,  training,  and  governance 
oversight. 

4. Documentation, ward rounds, and communication 

You  raised  concern  that  ward  staff  did  not  identify  that  Mrs  Patel  had  fallen,  reflecting  gaps  in 
documentation and communication. 

The Trust acknowledges that these failures contributed to a lack of shared situational awareness. 

Actions taken 
The  Trust  has  reinforced  expectations  that  all  inpatient  falls  and  significant  safety  events  are 
documented  contemporaneously  and  clearly  communicated  during  both  nursing  and  medical 
handover. 

All  inpatient  falls  occurring  out  of hours or  at weekends  are now required  to be  included  in  formal 
medical handover processes, ensuring visibility to the parent clinical team at the earliest opportunity. 
Nursing  handovers  are  required  to  explicitly  highlight  recent  falls  and  ongoing  monitoring 
requirements, supporting continuity across shifts. 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 Ward teams have been reminded that ward rounds and multidisciplinary reviews must include active 
consideration of events from the preceding 24–72 hours, including weekends. 

Ward  Managers  and  Nurses  in  Charge  provide  oversight  of  handover  processes,  with  particular 
attention to events occurring out of hours. 

Daily  multidisciplinary  board  rounds  have  been  strengthened  through  the  MBRACE  quality 
improvement programme, supporting structured review of patient risk, including falls and frailty, and 
improving shared situational awareness. 

Compliance  with  these  expectations  is  monitored  through  local  governance  processes  and 
escalated where gaps are identified. 

Status: Reinforced and monitored through leadership and governance oversight. 

Summary and assurance 

Barts Health NHS Trust recognises that the care provided to Mrs Patel did not consistently meet the 
standards expected, particularly in relation to falls prevention, post-fall escalation, clinical decision-
making, and communication. 

The  actions  described  above  represent  a  coordinated,  system-level  response  aimed  at  improving 
the  reliability  of  care,  strengthening  workforce  capability,  and  enhancing  clinical  oversight  and 
governance. 

Progress is monitored through audit, training compliance, and divisional governance structures, with 
oversight provided through the Trust’s Quality and Safety Committee. Where variation or gaps are 
identified, targeted actions are implemented and tracked to support continuous improvement. 

These measures are intended to reduce the likelihood of similar events occurring in the future and to 
support safer, more consistent care for patients at risk of falls and deterioration. 

Yours sincerely,                                                               

Medical Director 

Group Chief Medical Officer

Parliamentary Under-Secretary of State 

39 Victoria Street  
London  
SW1H 0EU  

Senior Coroner, Mr G Irvine 
East London Coroner’s Court 
Queens Road, Walthamstow 
E17 8QP 

Dear Mr Irvine 

Thank you for the Regulation 28 report of 26 February 2026 which you sent to the Secretary of 
State for Health and Social Care about the death of Urmila Patel. I am replying as the Minister with 
responsibility for Patient Safety.    

I would like to begin by saying how saddened I was to read of the circumstances of Mrs Patel’s 
death, and I offer my sincere condolences to her family and loved ones. The circumstances your 
report describes are concerning and I am grateful to you for bringing these matters to my attention.  

Your report raises concerns that: 

•  Nurses did not conduct an adequate falls risk assessment for Mrs Patel. 
•  Nursing staff failed to create a care plan for Mrs Patel's mobility. 
•  Trust staff missed a fall on 23rd June 2025 and did not reassess fall risk. 
•  Nursing staff did not monitor Mrs Patel on the afternoon 29th June 2025. 
•  The Trust staff did not assess the risk of an intra-cranial bleed after Mrs Patel’s fall on 29th 

June 

•  The duty doctor did not refer Mrs Patel for an urgent CT Head scan on 29th June 2025. 
•  The duty doctor did not review Mrs Patel's warfarin prescription post-fall. 
•  Ward staff failed to check previous clinical records during the ward round on 30th June 

2025, missing the alert about Mrs Patel’s fall on 29th June. 

Given the concerns you have raised I feel it is important that you receive a response directly from 
NHS England as it has oversight for the issues you raise. Therefore, my officials have contacted 
NHS England who have agreed to respond to you directly about the Prevention of Future Death 
report concerning Mrs Patel. 

I hope this response is helpful. Thank you for bringing these concerns to my attention. 

Yours sincerely, 

PARLIAMENTARY UNDER-SECRETARY OF STATE 
FOR HEALTH INNOVATION AND SAFETY