Source · Prevention of Future Deaths
Mohan Hothi
Ref: 2025-0513
Date: 14 Oct 2025
Coroner: Graeme Irvine
Area: East London
Responses identified: 0 / 1
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The Trust failed to investigate two serious unwitnessed falls, hindering its ability to identify and remediate suboptimal practices, with vague evidence of reflection and remediation.
Date
14 Oct 2025
56-day deadline
9 Dec 2025 est.
Responses identified
0 of 1
Coroner's concerns
The Trust failed to investigate two serious unwitnessed falls, hindering its ability to identify and remediate suboptimal practices, with vague evidence of reflection and remediation.
View full coroner's concerns
1. Mohan Singh Hothi died in hospital on 28th March 2025 due to injuries sustained in a fall at home in the early hours of the morning. During a previous hospital admission beginning in February 2025 and concluding on 20th March 2025 Mr Hothi sustained injuries in two separate unwitnessed falls, these injuries were serious (one requiring surgery) but could not be said to have contributed to his death. The two separate incidents were not assessed by the Trust as worthy of investigation through the Patient Safety Framework. This omission gives rise to a concern that future deaths may follow due to an inability on the part of the trust to identify, reflect upon, and remediate sub-optimal practice.
2. Evidence provided by the Trust at inquest to identify that reflection and remediation had been undertaken was vague and incomplete
2. Evidence provided by the Trust at inquest to identify that reflection and remediation had been undertaken was vague and incomplete
Report sections
Investigation and inquest
On 3rd April 2025, this court commenced an investigation into the death of Mohan Singh Hothi aged 76 years. The investigation concluded at the end of the inquest on 14/10/25. The court returned a short form conclusion of accidental death. Mr Hothi’s medical cause of death was determined as; 1a Traumatic Subdural Haemorrhage Following a Fall
Circumstances of the death
Mr Mohan Hothi was admitted to hospital on 28th of March following a fall at home. He was found to have a catastrophic subdural haematoma with midline shift. Mr Hothi was not assessed to be a suitable candidate for surgery, he died later that day.
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Report details
- Reference
- 2025-0513
- Date of report
- 14 October 2025
- Coroner
- Graeme Irvine
- Coroner area
- East London
Responses identified
Responses identified
0 of 1
1 response not yet linked
Organisations named in PFD reports are normally expected to respond within 56 days. Deadline: 9 Dec 2025 (estimated).
Sent to
- Barking, Havering and Redbridge University Hospitals NHS Trust