Source · Prevention of Future Deaths

Judith Hughes

Ref: 2025-0563 Date: 6 Nov 2025 Coroner: Simon Milburn Area: Cambridgeshire and Peterborough Responses identified: 1 / 1 View PDF

The hospital's fall risk assessment tool is confusing due to unclear factor definitions, risking incorrect scores, insufficient observation levels, and increased patient falls.

Date 6 Nov 2025
56-day deadline 1 Jan 2026 est.
Responses identified 1 of 1
Hospital Death (Clinical Procedures and medical management) related deaths

Coroner's concerns

AI summary
The hospital's fall risk assessment tool is confusing due to unclear factor definitions, risking incorrect scores, insufficient observation levels, and increased patient falls.
View full coroner's concerns
The Inquest heard evidence about the Trust's use of the 'Close Observation Risk Assessment' (p1903 Medical Records Bundle). This requires scores to be attributed to several factors including 'inpatient falls during this admission' and 'previous falls'. The overlap between these two factors and what they actually refer to is unclear and confusing. This creates a risk that the overall score may be calculated incorrectly resulting in insufficient levels of observation, increased risk of falls and death.

Responses

1 respondent
North West Anglia Foundation Trust NHS / Health Body
12 Nov 2025 PDF
Action Taken

The Trust revised the Enhanced Care Risk Assessment Form in 2022 following a routine review to clarify risk factors for patient falls. The policy and form are due for review again and the coroner's comments will be considered. (AI summary)

View full response
Dear Sir Inquest into the death of Judith HUGHES I refer to your Regulation 28 Report addressed to the Chief Medical Officer. This has been forwarded on to me as the Chief Nursing Officer. Mrs Hughes died over five years ago on 7th October 2020. Policies and Forms are, of course, subjected to regular review. As was mentioned at the inquest the relevant Form had already been revised in 2022 (a copy of the Policy which contains this is enclosed) following a routine review of the Policy. The Enhanced Care Risk Assessment Form is used by nursing staff to calculate the risk of a patient falling in hospital. You will note that the amended Form is clearer in setting out the risk factors. ‘Previous falls in the last 12 months’ essentially refers to falls outside of the hospital setting whereas ‘Inpatient fall during this admission’ refers to a new fall during the present admission. These are separate risk factors and the Form reflects this. Our nursing staff receive training on the Policy and Forms. The relevant Policy and Form are due to be reviewed again in the next few months and we will ensure that your comments are taken into account in this process.

Report sections

Investigation and inquest
On 16 October 2020 I commenced an investigation into the death of Judith Claire HUGHES aged 86. The investigation concluded at the end of the inquest on 05 November 2025. The conclusion of the inquest was that: Judith died from natural causes.
Circumstances of the death
Judith Hughes had a past medical history of significant heart disease. She was admitted to Peterborough City Hospital on 30 July 2020 following a tonic clonic seizure, where it was also identified that she was suffering from fast ventricular atrial fibrillation and a high heart rate. These issues were treated and Judith was discharged home on 30 July 2020 at which point there was no evidence that she was in cardiac failure. Judith's cardiac function declined from this point and she was further admitted to Peterborough City Hospital on 10 August 2020 when there was clear evidence of worsening heart failure. Sadly despite ongoing monitoring and care both in hospital and in the community Judith died at home, 129 Park Road in Peterborough, at 0030 hours on 07 October 2020.

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Report details

Reference
2025-0563
Date of report
6 November 2025
Coroner
Simon Milburn
Coroner area
Cambridgeshire and Peterborough

Responses identified

Responses identified 1 of 1
All listed responses identified

Organisations named in PFD reports are normally expected to respond within 56 days. Deadline: 1 Jan 2026 (estimated).

Sent to

Chief Medical Officer for North West Anglia Foundation Trust

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