Source · Prevention of Future Deaths

Kenneth Morris

Ref: 2026-0227 Date: 24 Apr 2026 Coroner: Paul Marks Area: Hull and East Riding Responses identified: 1 / 1 View PDF

Insufficient staffing meant the deceased did not receive required one-to-one nursing care, leading to a fall and death. The coroner noted that critically stretched NHS resources make similar incidents probable.

Date 24 Apr 2026
56-day deadline 19 Jun 2026
Responses identified 1 of 1

Coroner's concerns

AI summary
Insufficient staffing meant the deceased did not receive required one-to-one nursing care, leading to a fall and death. The coroner noted that critically stretched NHS resources make similar incidents probable.
View full coroner's concerns
This gentleman should have received one to one nursing care but due to a combination of understaffing and more pressing cases on the ward, he did not receive such care. Evidence was heard that had he received such care he would not have fallen and died. Evidence was also heard that within the Hull Trust and probably throughout the NHS, resources are critically stretched and whilst improvements are being proposed, I believe that the current situation makes it probable that similar deaths will occur.

Responses

1 respondent
Department of Health and Social Care
PDF
Received

No AI summary available.

Report sections

Investigation and inquest
On 23rd December 2025, I commenced an investigation into the death of Kenneth John Morris, formerly known as Kenneth John Pratt, age 78 years. The investigation  concluded at the end of the inquest on 13th April 2026. The conclusion of the inquest  was: ACCIDENT
Circumstances of the death
In the last eighteen months of his life, Kenneth Morris was losing weight unintentionally  and was becoming frail. He was also prone to falling. Following admission to hospital in  October 2025, he was diagnosed with bladder cancer. Following discharge from this and another admission in November 2025, his condition deteriorated, and he was readmitted to Hull Royal Infirmary on the 8th December 2025 with a working diagnosis of hypoactive delirium secondary to sepsis of unknown origin, malnutrition and frailty. He  was judged to be at high risk of falling. On the 9th December 2025, he had an  unwitnessed fall on the ward which was not associated with traumatic brain injury. He had a second fall on the ward on the 10th December 2025 which was complicated by  intracranial haemorrhage, constitutional damage to the brain and early post traumatic  epilepsy that resulted in his death at 04:09hours on the 10th December 2025. After his first fall, he should have received one to one nursing care and observation and had he done so, he would not have fallen, sustained a traumatic brain injury and died on the  10th December 2025 at Hull Royal Infirmary.
Action should be taken
possibly by reviewing funding and staffing numbers within the NHS at large.

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Report details

Reference
2026-0227
Date of report
24 April 2026
Coroner
Paul Marks
Coroner area
Hull and East Riding

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: 19 Jun 2026.

Sent to

Secretary of State for Health

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