PFD report

Mohan Singh Hothi · Prevention of Future Deaths report

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Issued 14 Oct 2025•East London

Report record

Published report and response evidence

This page connects the concerns raised in this report with statements found in recipients’ published responses. A link shows a clear evidence connection; it does not assign responsibility.

View original report
Concerns
3

Raised in this report

Recipients
1

Named on the report

Responses found
1

Of 1 recipient

Stated actions
5

Described in responses

Recipients and published responses

Source document

Full report text

This is the full text from the original published report.

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Concerns and recipient responses

Select any concern, action or position to view the source wording.

Concerns raised3

  1. Failure to identify, reflect upon, and remediate sub-optimal practice
    Part of recurring concern: Failure to identify and address recurring safety issues through organisational learning
  2. Failure to provide complete evidence of reflection and remediation
    Part of recurring concern: Unreliable PSIRF safety-incident decision and learning processes
  3. Failure to assess serious unwitnessed falls for investigation through the Patient Safety Framework
    Part of recurring concern: Inadequate safety incident investigationsPart of recurring concern: Unreliable formal safety-incident management processes
Responses linked to these concerns

Each statement is shown once, even when linked to more than one concern.

Actions described in response An action is something a recipient says it has done, is doing, or plans to do in response to a concern raised.5

  1. Action

    Review the post-fall action plan with nursing teams after every reported fall to ensure appropriate assessments and maintain patient safety.

    Stated by Barking, Havering and Redbridge University Hospitals NHS TrustStated completedThe respondent said that this action was complete when they made their response on 20 October 2025.
  2. Action

    Report all Geriatrics Care Group inpatient falls, including serious-harm incidents, to the Quality Governance and Steering Group and record escalation decisions for Trust Board reporting.

    Stated by Barking, Havering and Redbridge University Hospitals NHS TrustStated completedThe respondent said that this action was complete when they made their response on 20 October 2025.
  3. Action

    Commence covert observational audits across Geriatrics wards and departments to measure nursing response times to patient call bells and identify delays requiring further action.

    Stated by Barking, Havering and Redbridge University Hospitals NHS TrustStated plannedThe respondent said that this action was planned when they made their response on 20 October 2025.

Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.3

  1. Position

    Because the contributing factors were known and understood, no further investigation or learning response was considered necessary.

    Stated by Barking, Havering and Redbridge University Hospitals NHS TrustNo action considered necessaryThe respondent said that no further action was needed.

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Failure to identify, reflect upon, and remediate sub-optimal practice

Wider context from the report

“1. Mohan Singh Hothi died in hospital on 28th March 2025 due to injuries sustained in a fall at home in the early hours of the morning. During a previous hospital admission beginning in February 2025 and concluding on 20th March 2025 Mr Hothi sustained injuries in two separate unwitnessed falls, these injuries were serious (one requiring surgery) but could not be said to have contributed to his death. The two separate incidents were not assessed by the Trust as worthy of investigation through the Patient Safety Framework. This omission gives rise to a concern that future deaths may follow due to an inability on the part of the trust to identify, reflect upon, and remediate sub-optimal practice. 2. Evidence provided by the Trust at inquest to identify that reflection and remediation had been undertaken was vague and incomplete ”

Is this part of a recurring concern?

Yes — Failure to identify and address recurring safety issues through organisational learning.

Open source report

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Failure to provide complete evidence of reflection and remediation

Wider context from the report

“1. Mohan Singh Hothi died in hospital on 28th March 2025 due to injuries sustained in a fall at home in the early hours of the morning. During a previous hospital admission beginning in February 2025 and concluding on 20th March 2025 Mr Hothi sustained injuries in two separate unwitnessed falls, these injuries were serious (one requiring surgery) but could not be said to have contributed to his death. The two separate incidents were not assessed by the Trust as worthy of investigation through the Patient Safety Framework. This omission gives rise to a concern that future deaths may follow due to an inability on the part of the trust to identify, reflect upon, and remediate sub-optimal practice. 2. Evidence provided by the Trust at inquest to identify that reflection and remediation had been undertaken was vague and incomplete ”

Is this part of a recurring concern?

Yes — Unreliable PSIRF safety-incident decision and learning processes.

Open source report

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Failure to assess serious unwitnessed falls for investigation through the Patient Safety Framework

Wider context from the report

“1. Mohan Singh Hothi died in hospital on 28th March 2025 due to injuries sustained in a fall at home in the early hours of the morning. During a previous hospital admission beginning in February 2025 and concluding on 20th March 2025 Mr Hothi sustained injuries in two separate unwitnessed falls, these injuries were serious (one requiring surgery) but could not be said to have contributed to his death. The two separate incidents were not assessed by the Trust as worthy of investigation through the Patient Safety Framework. This omission gives rise to a concern that future deaths may follow due to an inability on the part of the trust to identify, reflect upon, and remediate sub-optimal practice. 2. Evidence provided by the Trust at inquest to identify that reflection and remediation had been undertaken was vague and incomplete ”

Is this part of a recurring concern?

Yes — Inadequate safety incident investigations; Unreliable formal safety-incident management processes.

Open source report

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Review the post-fall action plan with nursing teams after every reported fall to ensure appropriate assessments and maintain patient safety.

Verbatim wording from the response

“In February 2025, a total of 36 falls were reported, increasing to 45 falls in March 2025, compared with an average of approximately 25 falls per month in the Geriatrics Care Group. In response to this rise in falls and the associated risk of serious patient harm, the Head of Nursing and The Quality and Safety Advisor in Geriatrics implemented an action plan to address and monitor the situation. This action plan included the following measures:”

Source location

Response from Barking, Havering and Redbridge University Hospitals NHS Trust
Page 4 · response
Published 20 October 2025

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Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Report all Geriatrics Care Group inpatient falls, including serious-harm incidents, to the Quality Governance and Steering Group and record escalation decisions for Trust Board reporting.

Verbatim wording from the response

“4. All inpatient falls within the Geriatrics Care Group are reported to the Trust’s Quality Governance and Steering Group (QGSG), with any falls resulting in serious harm detailed. Decisions regarding escalation for a learning response are formally recorded and reported to the Trust Board.”

Source location

Response from Barking, Havering and Redbridge University Hospitals NHS Trust
Page 5 · response
Published 20 October 2025

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Commence covert observational audits across Geriatrics wards and departments to measure nursing response times to patient call bells and identify delays requiring further action.

Verbatim wording from the response

“Further action to be completed”

Source location

Response from Barking, Havering and Redbridge University Hospitals NHS Trust
Page 5 · response
Published 20 October 2025

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Discuss every reported fall at weekly Geriatrics Care Group incident reviews, share learning, and assess whether escalation for a wider learning response is required.

Verbatim wording from the response

“2. Every reported fall incident is discussed at the weekly Geriatrics Care Group incident review meeting, chaired by the Quality and Safety Advisor, to determine preventability, assess any harm sustained and share learning across the Care Group.”

Source location

Response from Barking, Havering and Redbridge University Hospitals NHS Trust
Page 4 · response
Published 20 October 2025

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Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Provide continuing Falls Lead communication and support to identify training needs and implement resulting training across the Geriatrics Care Group.

Verbatim wording from the response

“5. Ongoing communication and support from the Trust Falls Lead is provided to identify training needs which are subsequently implemented across the Care Group.”

Source location

Response from Barking, Havering and Redbridge University Hospitals NHS Trust
Page 5 · response
Published 20 October 2025

Open published response

Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Because the contributing factors were known and understood, no further investigation or learning response was considered necessary.

Verbatim wording from the response

“In accordance with the Patient Safety Incident Review Framework (PSIRF) and the Trust PSIRF plan, incidents are referred for a learning response when the contributing factors are not well understood or when there is potential for significant local or organisational learning. Following the review of incidents ████████, it was determined that the underlying factors were clearly understood – specifically that Mr Hothi chose to mobilise independently without awaiting assistance from nursing staff.”

Source location

Response from Barking, Havering and Redbridge University Hospitals NHS Trust
Page 3 · response
Published 20 October 2025

Open published response

Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

The inpatient falls were considered unpreventable, disputing that further investigation would identify preventable sub-optimal practice.

Verbatim wording from the response

“The investigations conducted under incident reference numbers ████████ concluded that both falls were unpreventable. Mr Hothi was assessed as having full mental capacity, displayed no signs of confusion, and was able to understand and follow instructions. Under these circumstances, patients are not provided with constant supervision, as they are deemed capable of communicating their care needs to the nursing staff. Moreover, continuous supervision would require the implementation of a Deprivation of Liberty Safeguards (DoLS) authorisation, for which Mr Hothi did not meet the criteria.”

Source location

Response from Barking, Havering and Redbridge University Hospitals NHS Trust
Page 2 · response
Published 20 October 2025

Open published response

Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Existing actions to manage the understood fall risk factors were considered sufficient, so no further investigation was required.

Verbatim wording from the response

“• The factors contributing to Mr Hothi’s falls were known and understood; therefore, no further investigation was required. Ongoing actions to manage these factors were already in place.”

Source location

Response from Barking, Havering and Redbridge University Hospitals NHS Trust
Page 3 · response
Published 20 October 2025

Open published response

Other statements in published responses

These actions and other statements could not be clearly connected to one concern in this report.

Recipient positions A position is what a recipient says about a concern when they do not describe a specific action.2

  1. 1

    No incidents during the hospital admissions were found to have caused or contributed to the death.

    Stated by Barking, Havering and Redbridge University Hospitals NHS TrustDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
  2. 2

    Continuous supervision was not implemented because it would require DoLS authorisation, and the patient did not meet the eligibility criteria.

    Stated by Barking, Havering and Redbridge University Hospitals NHS TrustUnable to actThe respondent said that a constraint prevented them from taking the relevant action.

Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

No incidents during the hospital admissions were found to have caused or contributed to the death.

Verbatim wording from the response

“• No incidents occurring during Mr Hothi’s hospital admissions were found to have caused or contributed to his death.”

Source location

Response from Barking, Havering and Redbridge University Hospitals NHS Trust
Page 3 · response
Published 20 October 2025

Open published response

Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Continuous supervision was not implemented because it would require DoLS authorisation, and the patient did not meet the eligibility criteria.

Verbatim wording from the response

“The investigations conducted under incident reference numbers ████████ concluded that both falls were unpreventable. Mr Hothi was assessed as having full mental capacity, displayed no signs of confusion, and was able to understand and follow instructions. Under these circumstances, patients are not provided with constant supervision, as they are deemed capable of communicating their care needs to the nursing staff. Moreover, continuous supervision would require the implementation of a Deprivation of Liberty Safeguards (DoLS) authorisation, for which Mr Hothi did not meet the criteria.”

Source location

Response from Barking, Havering and Redbridge University Hospitals NHS Trust
Page 2 · response
Published 20 October 2025

Open published response
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Information checked against the published report and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations

Data last updated 7 September 2026