Edwin Everett Milne Price · Prevention of Future Deaths report

On 18 November 2024 I commenced an investigation into the death of Edwin Everett Milne Price. The investigation concluded at the end of the inquest on 27 August 2025. The conclusion of the inquest was that Mr Price died having sustained injuries in a fall in hospital, to which gaps in his falls risk assessment and management made a contribution.

Mr Price lived at The Knoll Nursing Home in Yeovil where he was dependent on hoisting for all transfers. He had a history of falling onto the floor from his bed. There had been approximately twenty such incidents. The nursing home implemented mitigation measures of a low rise bed and a crash mat on the floor to minimise the risk of injury.

Mr Price was admitted to Yeovil District Hospital on 29 September 2024 with diabetic ketoacidosis. The oral evidence given by the Ward Manager at the inquest was that his falls risk assessment was not completed within the expected time of 24 hours from admission and that the expected communication about his falls risk with the nursing home did not take place. The hospital staff were therefore unaware of Mr Price’s specific risk of falling out of bed. No mitigation measures were implemented, namely moving Mr Price to a bay where he could be more easily observed, providing a low rise bed and providing a crash mat.

On 30 September 2024, Mr Price fell out of bed onto the floor. He sustained a fractured humerus and a retroperitoneal bleed, the latter being the cause of his death on 1 November 2024.

The medical cause of death provided by ████████ (Medical Examiner) was:

1a Retroperitoneal Haematoma

(anticoagulated)

II Type 1 Diabetes Mellitus; Pulmonary embolus

1. The falls risk assessment was not completed within the first 24 hours of admission to the ward.
2. Had it been completed, the risk assessment would have involved obtaining information from the nursing home as Mr Price was unable to communicate.
3. A risk assessment would have identified Mr Price’s specific risk of falling out of bed.
4. The lack of a risk assessment meant that mitigation measures were not in place.
5. The lack of mitigation measures made a more than minimal contribution to the extent of Mr Price’s injuries and therefore to his death.
6. No subsequent action has been taken by the ward to address the gaps in the falls risk assessment and management process when patients are admitted from care homes.