A senior coroner has issued a damning report to the Health Secretary, warning of an 'impossible situation' for NHS staff after two frail elderly men died a day apart in a South London hospital.
Deaths Contributed to by Neglect and Lack of Supervision
Fiona Wilcox, the Senior Coroner for Inner West London, found that 76-year-old David Ward and 83-year-old Dr Debapriya Ghosh died at St George's Hospital in Tooting in February 2024. Their deaths were a direct result of accidents contributed to by systemic failures.
Inquests concluded that Mr Ward died from a head injury sustained in a fall on February 10, with neglect a contributing factor. Dr Ghosh died the following day, on February 11, after an unwitnessed fall, with a failure to provide appropriate nursing supervision listed as a cause.
A&E Overwhelmed and Under-Resourced
The coroner's Prevention of Future Deaths report, sent to Health Secretary Wes Streeting, identified a critical lack of resources. It stated there were not enough beds or nurses to manage demand in the Accident and Emergency department when the men were present.
Both patients were left for hours, initially cared for by their families due to the overwhelming pressure on staff. Mr Ward was admitted on February 7 with frailty and confusion but received no significant nursing care after his daughter left in the early hours of February 8. He was later found kneeling by his bed with a fatal head injury.
Dr Ghosh, admitted on February 9 with delirium and an infection, was treated in a corridor for several hours before getting a bed. His nursing risk was not assessed until nearly midnight, and was not reassessed later despite his deteriorating condition.
Coroner's Stark Warning and Hospital Response
Coroner Fiona Wilcox warned that despite measures taken by St George's, A&E departments remain 'exceptionally busy' and the risk of further deaths persists. She highlighted the distress of staff managing 'impossible situations' where demand far exceeds available staff and facilities.
'In each case frail elderly men were left to wait for very many hours being cared for by their families, rather than supported by nurses,' the report said. 'When their families left during the night, they both fell as they were unsupervised.'
A spokesperson for St George's University Hospitals NHS Foundation Trust offered deepest sympathies and stated immediate changes were made. These included:
- Increasing staffing levels.
- Ensuring thorough falls risk assessments.
- Expanding the Same Day Emergency Care unit.
- Introducing a 'departure lounge' to free up beds.
However, the coroner emphasised that national government attention is required, as the underlying pressures of demand exceeding resources continue to pose a significant risk to patient safety across the NHS.
