Debapriya Ghosh and David Ward

I am Dr Fiona J Wilcox, HM Senior Coroner, for the Coroner Area of Inner West London

On 2nd December 2025 evidence was heard in two inquests touching the deaths of : Dr Debapriya Ghosh, who had died at St George’s Hospital on 11th February 2024 aged 83 years. Medical Cause of Death  la Subdural haemorrhage  lb Traumatic Head Injury II lschaemic heart disease. How, when and where the deceased came by his death. Dr Ghosh was admitted to St George’s Hospital on the morning of 9th  February  2024. The A&E department was exceptionally busy. He was initially cared for in the corridor and did not transfer to a cubicle until early evening. He was frail,  suffering with delirium, electrolyte imbalance, infection and a type II myocardial infarction. He was not risk assessed by the nursing staff until almost midnight. In the early hours of the morning of 10/2/2024 his delirium and agitation increased  such that medical advice was sought. However his nursing risk was not  reassessed, and he should have been escalated for 1:1 care. At around 08:30 he  had an unwitnessed fall and sustained a significant head injury that directly led to his death at 16:27 11/2/2024. If he had been allocated appropriate nursing  supervision his death would have been avoided. Conclusion of the coroner as to the death: Accidental fall contributed to by a failure to provide appropriate nursing _ supervision. Mr David Albert Ward who had died at St Goerges Hospital on 10th February 2024 aged 76 years. Medical cause of death: 1 a Subdural Haemorrhage 1 b Traumatic Head Injury II Non-Hodgkin Lymphoma How, when and where the deceased came by his death Mr Ward was admitted to St George’s Hospital with frailty, confusion and likely infection on 7/2 /2024. On 12/1/2024 he had emergency  surgery in Poole for colonic lymphoma. Due in part to acuity in A&E  he received no nursing risk assessments and following his daughter  leaving at approximately 02:30 8/2/2024 received no significant  nursing care. He was found kneeling by his bedside having suffered a  head injury which led to and caused his death on 10/2/2024 at 13:45. His nursing risk was such that he should have received enhanced care and if he had done so the fall and his death would have been avoided. Conclusion of the coroner as to the death. Accident contributed to by neglect.

Evidence Relevant to the Matters of Concern : Extensive evidence was taken from the families, nurses, doctors and pathologists. In each case it was clear that due to patient acuity there was insufficient  resource in terms of cubicles and bed spaces and insufficient nursing staff to manage the demand in the department. 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 and treated in proper bed  spaces. When their families left during the night, they both fell as they were  unsupervised, sustaining injuries that led to their deaths. Since the deaths St Georges Hospital has put in place systems to try and  allocate more nurses to A&E, divert frail patients to an elderly care unit, train and audit on risk assessments and make available health care assistants to help care and monitor patients who need 1:1 care amongst other matters. However evidence was taken during the inquest of Mr Ward that despite all  these measures many shifts in A&E are still exceptionally busy and feel little  different to how they were back in Feb 2024. This was clearly causing distress to the staff attempting to manage impossible situations where demand clearly  exceeds available resource in terms of staff and facilities.

That St George’s Hospital and other hospital A&E departments have  insufficient staff to manage demand during busy periods such that nursing risk cannot be managed without relying on families. That at work stress on A&E staff due to staff and resource shortages may  cause them to leave the profession exacerbating shortages of experienced staff and thus increase risks in A&E. That local hospitals such as St George’s have implemented multiple actions within their power to attempt to manage demand and risk, but these have  been insufficient such that risk remains, and so central consideration should be given to the issues. That it is unsafe for families to leave their loved ones unsupervised in overcrowded A&E departments.

In my opinion action should be taken to prevent future deaths and I believe you  [AND/OR your organisation] have the power to take such action. It is for each addressee to respond to matters relevant to them