John McKinlay

[250-word statement addressing what circumstances of the death have led to the coroner’s concern, and why the coroner thinks the person to whom the report is directed is responsible for  taking action to prevent future deaths. This statement must not propose what action should be  taken, as coroners cannot make recommendations].  The evidence from witnesses was that Mr McKinlay had a total of 4 falls whilst an inpatient at the  University Hospitals of Birmingham: on the 11th September 2025 at Good Hope Hospital, 28th  September 2025 at Birmingham Heartlands Hospital and on the 10th and 12th November 2025  at Queen Elizabeth Hospital. Some, potentially all, of these falls occurred when Mr McKinlay was  not receiving the appropriate level of observation in accordance with his falls risk assessment  and care plan. He sustained a femur fracture requiring operative fixation from the fall on the 11th  September and an acute bleed of a pre-existing subdural haemorrhage on the 28th September.  He did not have any investigations into the November falls as he was already receiving end of life care and there was no clinical evidence of injury. There has been a mortality review of the  events at Good Hope Hospital, including the fall on the 11th September. However, evidence has  not been provided of investigations into the falls at Birmingham Heartlands Hospital and Queen  Elizabeth Hospital. It therefore cannot be determined that appropriate lessons have been learnt  and adequate action taken creating a risk the situation has not improved.