Mohan Hothi
PFD Report
No Identified Response
Ref: 2025-0513
109 days past deadline · No identified published response
Response Status
Responses
0 of 1
56-Day Deadline
9 Dec 2025
109 days past deadline — no identified published response
About PFD responses
Organisations named in PFD reports must respond within 56 days explaining what actions they are taking.
Source: Courts and Tribunals Judiciary
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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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.