Death of a UHB patient following an unwitnessed fall: Coroner’s PFD report

By Dr Minh Alexander retired consultant psychiatrist 21 May 2023

University Hospitals Birmingham NHS Foundation Trust received a warning notice for under-staffing from the Care Quality Commission in December 2022 following an unannounced inspection of Good Hope Hospital over 7-14 December 2022.

The inspection took place just after BBC Newsnight broadcast about poor culture and mistreatment of staff at the trust. The CQC claimed it inspected “due to a number of concerns raised by patients and their families around the care and treatment they had received”.

The warning notice on under-staffing was served partly as the CQC found that patient falls, some with serious harm, occurred DURING the inspection:

“Staff knew about and dealt with many specific risk issues. However, in many ward areas staff told us about their concerns over the number of falls and patients with pressure damage due to staffing pressures preventing them from taking appropriate, preventative action. On the first day of our inspection, staff reported that they had unfortunately had 2 patients fall due to being unable to provide the supervision the patients were assessed as requiring.

“The service did not have enough nursing and support staff to keep patients safe. During our inspection we found most wards were operating below national guidance for safe staffing levels. The Royal College of Nursing recommend safe staffing levels of 1 qualified nurse to 6 patients. Staff told us shifts were regularly planned for 3 qualified members on staff each shift, however this regularly reduced to only 2 qualified staff members working on the shift. Even with 3 qualified nurses on each shift, this would still have been outside of the recommended safe staffing levels. On the 13 December 2022, we found Ward 16 which had medical outlier patients admitted at the time were reduced to 1 qualified member of staff for 26 patients, at the time of our visit. The registered nurse was supported by a trained nursing associate. On the 13 and 14 December 2022, we found Ward 9 had a ratio of 1 nurse to 17 patients on both days of our inspection. Staff told us the ward had a high acuity as they had a large number of patients with complex needs, many of whom required 1:1 supervision. At the time of our inspection, staff were unable to provide this due to the unsafe staffing levels. On the first day of our inspection, Ward 9 reported 2 falls as they were unable to provide the 1:1 support for them. One patient did not sustain serious harm, however, 1 patient was awaiting a head CT scan and undergoing neurological observations due to the fall. Staff told us this was not a rare occurrence due to the challenges they faced with staffing.

We raised our concerns about staffing during and after our inspection and issued the trust with a Section 29a Warning Notice advising them of timely improvements needed to be made due to serious safety concerns.”

UHB trust board papers show that inpatient falls with “severe” and “catastrophic” harm occur on a regular basis.

It raises a question of why the CQC only served a warning notice and is not actively investigating under Regulation 12.

Another UHB hospital has now been criticised in relation to a patient fall which resulted in death.

On 19 May 2023 the coroner issued a Prevention of Future Deaths report after the death of 77 year old Norma Bruton who had an unwitnessed fall at Heartlands Hospital, resulting in a fractured neck of femur and her death seven days later.

Norma Bruton Prevention of Future Deaths report 19 May 2023 Ref Ref: 2023-0165

The death occurred on 22 October 2022, shortly before the unannounced CQC inspection of Good Hope Hospital in December 2022.

“She had an unwitnessed fall on the morning of 15 October 2022 when trying to walk the short distance to her bathroom and sustained a right fractured neck of femur for which she underwent surgery on 20 October 2022. Mrs Bruton’s condition deteriorated after the surgery and she died in hospital on 22 October 2022.”

The coroner identified a concern about UHB’s falls risk assessment process and failure to take trailing attachments such as drains and drip lines into consideration as risk factors.

Bewick’s rapid review of clinical safety at UHB, published in March 2023 claimed that UHB was safe overall, despite Bewick’s awareness of the CQC warning at Good Hope Hospital. Bewick’s report maintained that mitigations were in place.

The issues of serious understaffing across all UHB sites, about which staff have been whistleblowing for years according to UNISON and others, supported by regulatory findings, long A&E waits and rates of avoidable harm from falls, are not consistent with a conclusion that clinical care at UHB is reliably safe.

Neither is the upsurge in concerns reported by the public to Healthwatch since 2021.

Will other care failings continue to emerge?

I am sending the PFD on Ms Norma Bruton’s death to the Care Quality Commission with respect to Regulation 12 issues. The Coroner has already sent it to NHS England.

NB I am occupied with a family matter at present so apologies if I am slow to respond to correspondence. Best wishes.


A previous UHB FOI disclosure revealed that there were 30 fractured necks of femur resulting from inpatient falls in the period 2012/13

Another UHB FOI disclosure showed that the majority of inpatient falls at UHB are unobserved:

One thought on “Death of a UHB patient following an unwitnessed fall: Coroner’s PFD report

  1. Thank you, Dr A.
    Any fall, let alone death after a fall, is worthy of investigation and not normalised into routine matters.
    What a disgrace.
    The lack of suitable punishment for those responsible – a disgrace.
    In addition, one can only imagine the chronic distress of the patients as they await help to relieve themselves. Thus, both physical and psychological distress are normalised – a disgrace.
    Is it a hopeless dream that one day our ‘caring’ industry would actually care and might even consider health and wellbeing as an achievable outcome rather than injury and death?
    Btw, I feel very sorry for the overwhelmed staff trying to cope with an impossible situation.
    Kindest, Zara.


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