Colin Colley

I am Rachel Knight Assistant Coroner , for the coroner area of South Wales Central.

On 24 October 2023 I commenced an investigation into the death of Colin Colley. The  investigation concluded at the end of the inquest on 12 th March 2025. The conclusion of  the inquest was a narrative: Colin Colley was aged 87 when on 14th October 2023 he died at the University Hospital of  Wales, Cardiff. Colin suffered with a number of comorbidities including dementia and frailty, and he was anticoagulated for atrial fibrillation. Colin suffered an unwitnessed fall  from bed on 11th October, when he was an inpatient at St. David’s Hospital, Cardiff. He was known to wander from his bed in hospital, and had fallen previously, and he had been  assessed as being at high risk of falls. His restlessness and cognitive decline indicated that his cot sides should have been left down. He had been assessed as requiring one-to-one  supervision. At the time of Colin’s final fall, he had been left unsupervised and bed rails were in place, in error. He sustained a fatal brain bleed, and was transferred to the University Hospital of  Wales, where sadly his condition deteriorated until his death. 1a   Intracranial haemorrhage 1b   Unwitnessed fall with traumatic head injury 1c   Vascular dementia, frailty of old age II    Atrial fibrillation (treated)

Mr Colley was left unsupervised with cot sides up. He climbed out and fell sustaining a fatal head injury. He should not have been left unsupervised and his cot sides should not have been up. The Inquest focused upon:- a. Mr Colley’s risk of falling; and b. The use of the Enhanced Supervision Document;.

During the course of the inquest the evidence revealed matters giving rise to concern. In  my opinion there is a risk that future deaths will occur unless action is taken. In the  circumstances it is my statutory duty to report to you. The MATTERS OF CONCERN are as follows. (1)  Evidence was taken from nurses at St David’s that there remains a lack of confidence in both qualified nursing staff, healthcare assistants and healthcare support workers in the  use of and implication of risk assessments around falls, and the use of and importance of  enhanced supervision and the Enhanced Supervision Document. I am concerned that  unless more training is provided and refreshed frequently, there is a risk of future deaths  occurring, particularly given the cohort being nursed at that hospital and the turnover of  staff.

In my opinion action should be taken to prevent future deaths and I believe you and your organisation have the power to take such action.