The coroner has written a Prevention of Future Deaths Report
The exterior of Castle Hill Hospital in Cottingham, Hull, East Yorkshire(Image: Donna Clifford for Hull Daily Mail)
A coroner has written a report after an elderly man sadly died days after an unwitnessed fall on a ward at Castle Hill Hospital, which an inquest heard likely contributed to his death. Raymond John Moran, 82, sadly passed away last Christmas Eve (December 24, 2025).
Mr Moran fell while a patient on ward 32 at the Cottingham hospital on December 13. As a result, he suffered a broken leg, which coroner Professor Paul Marks said “more than minimally, negligibly or trivially contributed to his death”.
Prof Marks, who is the senior coroner for Hull and East Yorkshire, said Mr Moran had a history of falls. Just two months before, he had broken a bone in his neck after a fall at home.
“Although a falls risk assessment had been carried out and Raymond adjudged as a moderate risk, in retrospect, he should have been categorised as a high risk of falling,” said Prof Marks.
The coroner acknowledged Mr Moran’s “life span was unlikely to have been long” due to having a number of other serious illnesses.
Prof Marks said: “Evidence was heard at inquest that not only was the falls risk assessment inaccurate, but also, it was not updated as it should have been. In addition, the documentation was incomplete.”
He concluded: “In my opinion action should be taken to prevent future deaths and I believe you and your organisation has the power to take such action.
“This may include, for example, ensuring that appropriate assessments take place that capture all relevant information about falls that have recently taken place in the community, emphasis is placed on filling out forms accurately and contemporaneously, and ensuring training and auditing of in-hospital falls continues and can be demonstrated and evidenced.”
Prof Marks’ report was sent to NHS England and Humber Health Partnership, which runs Hull University Teaching Hospitals NHS Trust. They have a deadline of April 22 to respond.
A spokesperson for Humber Health Partnership said: “We would like to express our sincere condolences to Mr Moran’s family and apologise for the distress caused by the circumstances of his care.
“We have received the Coroner’s Prevention of Future Deaths Report and are carefully reviewing the Coroner’s findings. We will respond formally within the required timeframe.
“The trust is committed to learning from inquests and to continuously improving patient care, including the accuracy of clinical documentation, risk assessment and falls prevention processes.”
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