Raymond John MORAN · Prevention of Future Deaths report

On 12th January 2026, I commenced an investigation into the death of Raymond John MORAN, aged 82 years. The investigation concluded at the end of the inquest on 11th February 2026, the narrative conclusion of the inquest was:-

Raymond John Moran had an unwitnessed fall on 13th December 2025 whilst a patient on ward 32 at Castle Hill Hospital which resulted in a subtrochanteric fracture of his right femur. This in conjunction with his co-morbidities, including metastatic prostate cancer and bilateral pulmonary emboli, more than minimally, negligibly or trivially contributed to his death on 24th December 2025.

Raymond John Moran had a significant history of metastatic prostate cancer, ischaemic heart disease and atrial fibrillation for which he received apixaban. He has a fall at his home on 31st October 2025 which resulted in the development of a fracture of the left femoral neck. This was successfully treated surgically, and he went into rehabilitation thereafter. Whilst there, he developed breathing difficulties which were investigated and were found to be due to bilateral pulmonary emboli, which occurred even in the presence of anticoagulant therapy for his atrial fibrillation. He was readmitted to hospital and his anticoagulation therapy increased. Whilst on Ward 32 at Castle Hill Hospital, he had an unwitnessed fall which resulted in a subtrochanteric comminuted fracture of the right femur. Due to his anticoagulation requirements and diminished physiological reserve, although consideration was initially given for him to have further surgery, it was subsequently ruled out due to his co-morbidities. He died on the 24th December 2025. 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. His fractures were not due to metastatic deposits in the femora but were osteoporotic, and this disorder was contributed to by the treatment he had received, which included dexamethasone for his prostatic cancer. The fall on ward 32 more than minimally, trivially or negligibly contributed to his death although his life span was unlikely to have been long due to his known comorbidities.

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.