Dr Debapriya Ghosh and Mr David Albert Ward · Prevention of Future Deaths report

On 2nd December 2025 evidence was heard in two inquests touching the deaths of :

1. Dr Debapriya Ghosh, who had died at St George’s Hospital on 11th February 2024 aged 83 years.

Medical Cause of Death

Ia Subdural haemorrhage
Ib Traumatic Head Injury

II Ischaemic heart disease.

How, when and where the deceased came by his death.

Dr Ghosh was admitted to St George’s Hospital on the morning of 9th February 2024. The A&E department was exceptionally busy. He was initially cared for in the corridor and did not transfer to a cubicle until early evening. He was frail, suffering with delirium, electrolyte imbalance, infection and a type II myocardial infarction. He was not risk assessed by the nursing staff until almost midnight. In the early hours of the morning of 10/2/2024 his delirium and agitation increased such that medical advice was sought. However his nursing risk was not reassessed, and he should have been escalated for 1:1 care. At around 08:30 he had an unwitnessed fall and sustained a significant head injury that directly led to his death at 16:27 11/2/2024. If he had been allocated appropriate nursing supervision his death would have been avoided.

Conclusion of the coroner as to the death:

Accidental fall contributed to by a failure to provide appropriate nursing supervision.

2. Mr David Albert Ward who had died at St Georges Hospital on 10th February 2024 aged 76 years.

Medical cause of death:

1a Subdural Haemorrhage
1b Traumatic Head Injury

II Non-Hodgkin Lymphoma

How, when and where the deceased came by his death

Mr Ward was admitted to St George’s Hospital with frailty, confusion and likely infection on 7/2/2024. On 12/1/2024 he had emergency surgery in Poole for colonic lymphoma. Due in part to acuity in A&E he received no nursing risk assessments and following his daughter leaving at approximately 02:30 8/2/2024 received no significant nursing care. He was found kneeling by his bedside having suffered a head injury which led to and caused his death on 10/2/2024 at 13:45.

His nursing risk was such that he should have received enhanced care and if he had done so the fall and his death would have been avoided.

Conclusion of the coroner as to the death.

Accident contributed to by neglect.

1. That St George’s Hospital and other hospital A&E departments have insufficient staff to manage demand during busy periods such that nursing risk cannot be managed without relying on families.

2. That at work stress on A&E staff due to staff and resource shortages may cause them to leave the profession exacerbating shortages of experienced staff and thus increase risks in A&E.

3. That local hospitals such as St George’s have implemented multiple actions within their power to attempt to manage demand and risk, but these have been insufficient such that risk remains, and so consideration should be given to the issues.

4. That it is unsafe for families to leave their loved ones unsupervised in overcrowded A&E departments.