Colin Colley · Prevention of Future Deaths report

On 24 October 2023 I commenced an investigation into the death of Colin Colley. The investigation concluded at the end of the inquest on 12ᵗʰ March 2025. The conclusion of the inquest was a narrative:

Colin Colley was aged 87 when on 14th October 2023 he died at the University Hospital of Wales, Cardiff. Colin suffered with a number of comorbidities including dementia and frailty, and he was anticoagulated for atrial fibrillation. Colin suffered an unwitnessed fall from bed on 11th October, when he was an inpatient at St. David's Hospital, Cardiff. He was known to wander from his bed in hospital, and had fallen previously, and he had been assessed as being at high risk of falls. His restlessness and cognitive decline indicated that his cot sides should have been left down. He had been assessed as requiring one-to-one supervision.

At the time of Colin's final fall, he had been left unsupervised and bed rails were in place, in error. He sustained a fatal brain bleed, and was transferred to the University Hospital of Wales, where sadly his condition deteriorated until his death.

1a Intracranial haemorrhage

1b Unwitnessed fall with traumatic head injury

1c Vascular dementia, frailty of old age

II Atrial fibrillation (treated)

Mr Colley was left unsupervised with cot sides up. He climbed out and fell sustaining a fatal head injury. He should not have been left unsupervised and his cot sides should not have been up.

The Inquest focused upon:-

a. Mr Colley’s risk of falling; and

b. The use of the Enhanced Supervision Document,:

(1) Evidence was taken from nurses at St David’s that there remains a lack of confidence in both qualified nursing staff, healthcare assistants and healthcare support workers in the use of and implication of risk assessments around falls, and the use of and importance of enhanced supervision and the Enhanced Supervision Document. I am concerned that unless more training is provided and refreshed frequently, there is a risk of future deaths occurring, particularly given the cohort being nursed at that hospital and the turnover of staff.