On 2nd March 2015 commenced an investigation into the death of Thomas Luke-Taylor: The investigation concluded at the end of the inquest on 2" March 2015. The conclusion of the inquest was that "The deceased who had had a stroke fell out of bed and sustained an injury whilst in Bishop Auckland General Hospital: A conclusion of Accidental Death was returned and a cause of death of Ia, Sub-Dural Haematoma: Ib, Head Injury secondary to a Fall and 2, Cerebro-Vascular Disease, Bronchopneumonia and Fractured Left Femur; was found. CiRCUMSTANCES OF THE DEATH The deceased who had had a stroke was in the Stroke Rehabilitation Ward at Bishop Auckland General Hospital where he fell out of bed, suffered a head injury and subsequently died. On admission to the University Hospital of North Durham a staff nurse assessed him as not being at risk of falls. He was admitted following transfer from the Royal Victoria Hospital in Newcastle where he had been assessed at risk of falls following his stroke but the staff nurse was not aware of this. On transfer to Bishop Auckland Hospital a student nurse completed a falls risk assessment and wrongly categorised the deceased as not at risk of falls. Her involvement in deceased's care was not properly supervised by a staff nurse_ In evidence it was said that the staff nurse who made the initial assessment at UHND made the assessment in good faith based on her professional assessment but that she was relatively inexperienced. Two other staff nurses who were both more experienced, believed that the fact that the deceased had had a previous stroke would have made him more likely to have been at risk of falls and in the absence of any contraindication would have assessed him as being at risk of falls. The matron who produced the RCS concurred that stroke patients were often at increased risk of falls

In my opinion action should be taken to prevent future deaths and believe your organisation have the power to take such action: Your RESPONSE You are under a duty to respond to this report within 56 days of the date of this report , namely by 28" April, the coroner, may extend the period. Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise you must explain why no action is proposed.