Kenneth John Morris · Prevention of Future Deaths report

On 23rd December 2025, I commenced an investigation into the death of Kenneth John Morris, formerly known as Kenneth John Pratt, age 78 years. The investigation concluded at the end of the inquest on 13th April 2026. The conclusion of the inquest was: ACCIDENT

In the last eighteen months of his life, Kenneth Morris was losing weight unintentionally and was becoming frail. He was also prone to falling. Following admission to hospital in October 2025, he was diagnosed with bladder cancer. Following discharge from this and another admission in November 2025, his condition deteriorated, and he was readmitted to Hull Royal Infirmary on the 8th December 2025 with a working diagnosis of hypoactive delirium secondary to sepsis of unknown origin, malnutrition and frailty. He was judged to be at high risk of falling. On the 9th December 2025, he had an unwitnessed fall on the ward which was not associated with traumatic brain injury. He had a second fall on the ward on the 10th December 2025 which was complicated by intracranial haemorrhage, constitutional damage to the brain and early post traumatic epilepsy that resulted in his death at 04:09hours on the 10th December 2025. After his first fall, he should have received one to one nursing care and observation and had he done so, he would not have fallen, sustained a traumatic brain injury and died on the 10th December 2025 at Hull Royal Infirmary.

This gentleman should have received one to one nursing care but due to a combination of understaffing and more pressing cases on the ward, he did not receive such care. Evidence was heard that had he received such care he would not have fallen and died. Evidence was also heard that within the Hull Trust and probably throughout the NHS, resources are critically stretched and whilst improvements are being proposed, I believe that the current situation makes it probable that similar deaths will occur.