Source · Prevention of Future Deaths
Pamela Hindley
Ref: 2026-0404
Date: 10 Aug 2026
Coroner: Guy Davies
Area: Cornwall & the Isles of Scilly
0 responses identified · 1 indexed addressee
View PDF
Response deadline: 5 October 2026 (stated in the report).
Date
10 Aug 2026
56-day deadline
5 Oct 2026
stated in the report
Responses identified
0 of 1
Coroner's concerns
Rapid discharge events put significant pressure on hospital staff and community services and increases the risk of patients being discharged without sufficient care provision including necessary aids and adaptations to the home environment necessary to ensure the safety of those discharged from hospital. The root cause of the need for the rapid discharge event was...
View full coroner's concerns
Rapid discharge events put significant pressure on hospital staff and community services and increases the risk of patients being discharged without sufficient care provision including necessary aids and adaptations to the home environment necessary to ensure the safety of those discharged from hospital.
The root cause of the need for the rapid discharge event was inadequate social care provision, this being an ongoing situation.
The court found significant numbers of patients in hospital who are medically fit for discharge and with no reason to reside in hospital (NCTR) but cannot be discharged due to lack of available social care provision (whether commissioned by social services or NHS). At times up to 20% of patients in RCHT have NCTR status. This creates pressure on bed availability on hospital wards and impedes patient flow through the hospital. This in turn leads to other issues such as crowding and corridor care in the emergency department, patients in ambulances, and ambulance delays in the community.
The court noted investigations in 2022 and 2023 by South West Ambulance Trust (SWAST) and the Healthcare Safety Investigation Branch (HSIB) which found a direct link between ambulance delays and inadequate social care provision. The court noted the SWAST systems report which found…
‘’….there is a direct link between patients waiting in the hospital for discharge to social care and patients being cared for inside ambulances and Emergency Departments.’’
The root cause of the need for the rapid discharge event was inadequate social care provision, this being an ongoing situation.
The court found significant numbers of patients in hospital who are medically fit for discharge and with no reason to reside in hospital (NCTR) but cannot be discharged due to lack of available social care provision (whether commissioned by social services or NHS). At times up to 20% of patients in RCHT have NCTR status. This creates pressure on bed availability on hospital wards and impedes patient flow through the hospital. This in turn leads to other issues such as crowding and corridor care in the emergency department, patients in ambulances, and ambulance delays in the community.
The court noted investigations in 2022 and 2023 by South West Ambulance Trust (SWAST) and the Healthcare Safety Investigation Branch (HSIB) which found a direct link between ambulance delays and inadequate social care provision. The court noted the SWAST systems report which found…
‘’….there is a direct link between patients waiting in the hospital for discharge to social care and patients being cared for inside ambulances and Emergency Departments.’’
Report sections
Investigation and inquest
On 2 December 2024 I commenced an investigation into the death of 80-year-old Pamela. The investigation concluded at the end of the inquest on 1 July 2026.
The medical cause of death was established on the evidence as follows: 1a Left Subdural Haematoma 1b Fall 2 Frailty of Old Age, Chronic eosinophilic leukaemia
The four questions – who, when, where and how – were answered as follows: Pamela Margaret HINDLEY died on 23 November 2024 at Royal Cornwall Hospital Treliske Truro from trauma consistent with an unwitnessed fall at her home contributed to by frailty of old age and leukaemia. The unwitnessed fall followed a discharge from hospital one week earlier in circumstances in which Pamela’s mobility was reduced to mobilising with a frame. The community services had not been able to provide the necessary aids and adaptations to Pamela’s home before her discharge, and before she suffered her fatal fall. Pamela was not able to give an account of why she fell and it is not possible to determine whether the absence of aids and adaptations caused or contributed to her fatal fall. My conclusion as to the death was as follows: Accident
The medical cause of death was established on the evidence as follows: 1a Left Subdural Haematoma 1b Fall 2 Frailty of Old Age, Chronic eosinophilic leukaemia
The four questions – who, when, where and how – were answered as follows: Pamela Margaret HINDLEY died on 23 November 2024 at Royal Cornwall Hospital Treliske Truro from trauma consistent with an unwitnessed fall at her home contributed to by frailty of old age and leukaemia. The unwitnessed fall followed a discharge from hospital one week earlier in circumstances in which Pamela’s mobility was reduced to mobilising with a frame. The community services had not been able to provide the necessary aids and adaptations to Pamela’s home before her discharge, and before she suffered her fatal fall. Pamela was not able to give an account of why she fell and it is not possible to determine whether the absence of aids and adaptations caused or contributed to her fatal fall. My conclusion as to the death was as follows: Accident
Circumstances of the death
Pamela was frail and a falls risk with limited mobility following a discharge from Royal Cornwall Hospital Treliske Truro (RCHT) on 15 November 2024. On discharge Pamela had been reduced to mobilising by way of zimmer frame. The discharge took place against a background of a planned rapid discharge event at RCHT in which the hospital wards and community services were required to work together to reach certain targets of numbers of patients discharged. These targets were well above the usual rate of discharges and created significant pressure on ward staff and community services.
Therapy paperwork was not completed during the preparation for the rapid discharge of Pamela. This resulted in a missed opportunity to alert community services to the need to conduct an assessment of the safety of Pamela’s home environment. The home assessment did not take place until after Pamela’s discharge. There was then a delay in arranging the necessary adaptations to Pamela’s home. These included the installation of grab rails around the property and the uncluttering of the bedroom which contained a double bed which needed to be moved and replaced with a single bed in order to ease restricted movement in that room.
One week after discharge and just before the adaptations were to be implemented Pamela suffered an unwitnessed fall in the bedroom and sustained a catastrophic head injury. Pamela did not regain consciousness before dying. It was not possible to determine the reason for the fall and whether the absence adaptations contributed.
It was found that with sufficient notice before discharge, these adaptations could have been implemented.
Therapy paperwork was not completed during the preparation for the rapid discharge of Pamela. This resulted in a missed opportunity to alert community services to the need to conduct an assessment of the safety of Pamela’s home environment. The home assessment did not take place until after Pamela’s discharge. There was then a delay in arranging the necessary adaptations to Pamela’s home. These included the installation of grab rails around the property and the uncluttering of the bedroom which contained a double bed which needed to be moved and replaced with a single bed in order to ease restricted movement in that room.
One week after discharge and just before the adaptations were to be implemented Pamela suffered an unwitnessed fall in the bedroom and sustained a catastrophic head injury. Pamela did not regain consciousness before dying. It was not possible to determine the reason for the fall and whether the absence adaptations contributed.
It was found that with sufficient notice before discharge, these adaptations could have been implemented.
Copies sent to
I can confirm I have sent the report to3. RCHT4. SWAST5. Disability Cornwall6. The Community Helping All of Society Group Cornwall (CHAOS)
Similar PFD reports
Report details
- Reference
- 2026-0404
- Date of report
- 10 August 2026
- Coroner
- Guy Davies
- Coroner area
- Cornwall & the Isles of Scilly
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: 5 Oct 2026 (stated in the report).
Sent to
- Department of Health and Social Care