Urmila Patel

I am Graeme Irvine, senior coroner, for the coroner area of East London

On 08/17/2025 this Court commenced an investigation into the death of Urmila Patel aged 78-years. The investigation concluded at the end of the inquest on 24/02/2026. The Court returned a short-form conclusion of “accident compounded by neglect”. Mrs Patel’s medical cause of death was determined as; 1a Acute Subdural Haematoma

Urmila Patel was a 78 year old woman who was admitted to Newham University Hospital (“NUH”) in relation to suspected sepsis on 10 th June 2025. Mrs Patel was admitted onto Thistle ward, where appropriate falls risk assessments were not undertaken. No clear care plan was produced to address risks related to her mobility. On the afternoon of 29 th June 2025, Mrs Patel sustained a fall whilst in the ward toilet. At the time of the fall, she was not being adequately supported by ward staff. In the immediate aftermath of the fall a medical review was sought, during which Mrs Patel’s son told hospital staff that his mother had struck her head. Despite his account, Mrs Patel’s warfarin medication was not discontinued, and no request was made for a CT scan of Mrs Patel’s head. In the days that followed Mrs Patel deteriorated and on Tues 1/7/25 another medical review was triggered due to Mrs Patel’s lowered consciousness and facial droop. At this stage an urgent CT head scan was undertaken which showed a significant subdural haematoma which was placing pressure on her brain, causing a midline shift. At this stage Mrs Patel’s warfarin was held, she was deemed not to be a safe candidate for neurosurgery. Mrs Patel died in hospital on 7 th July 2025.

During the course of the inquest the evidence revealed matters giving rise to concern. In my opinion there is a risk that future deaths could 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. The failure of nurses on the ward to instigate an adequate falls risk

assessment of Mrs Patel.

1. The failure of nursing staff on the ward to produce a meaningful care-plan

for Mrs Patel’s mobility.

1. The failure of Trust staff to note a fall on 23

rd June 2025 and reassess risk of falls.

1. The failure of nursing staff on the ward to monitor and supervise Mrs Patel on the afternoon of 29

th June 2025.

1. The failure of Trust staff to adequately assess the likelihood of a traumatic

intra-cranial bleed following the fall on 29 th June 2025.

1. The failure of the duty doctor to act decisively and refer Mrs Patel for an

urgent CT Head scan on 29 th June 2025.

1. The failure of the duty doctor to review Mrs Patel’s warfarin prescription

after the fall.

1. The failure of ward staff on the ward round on 30

th June 2025 to read the clinical records from the previous day to alert them to Mrs Patel’s fall on 29 th June 2025.

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.