Two frail elderly men died preventable deaths at St George’s Hospital after being left unsupervised in an overcrowded accident and emergency department, a coroner has found, warning that despite changes made by the hospital, staff still face “impossible situations” where demand exceeds resources.
David Ward, 76, and Dr Debapriya Ghosh, 83, both died from head injuries after falling while unsupervised at the hospital in February 2024. Their families had been caring for them during long waits before leaving overnight, when both men fell and sustained injuries that led to their deaths the following day.
Senior Coroner Dr Fiona Wilcox concluded that Ward’s death was an “accident contributed to by neglect” and Ghosh’s death was an “accidental fall contributed to by a failure to provide appropriate nursing supervision.” In both cases, she found the deaths would have been avoided if the men had received the care they needed.
The coroner’s Prevention of Future Deaths report, published last month and sent to Health Secretary Wes Streeting, warns that while St George’s has implemented multiple changes since the deaths, evidence at the inquests showed “many shifts in A&E are still exceptionally busy and feel little different to how they were back in Feb 2024.”
St George’s told Putney.news that falls in the emergency department have dropped by 30% since February 2024 following the changes, which included increasing staffing levels and ensuring thorough falls assessments. However, the hospital did not say whether it agrees with staff evidence that conditions feel little different, and declined to answer questions about when it will respond to the Health Secretary or whether the coroner report was discussed at this week’s Board meeting.
‘Cared for by their families, rather than supported by nurses’
Ward was admitted to St George’s Hospital on 7 February 2024 with frailty, confusion and likely infection. The coroner’s report states he received no nursing risk assessments and, after his daughter left at approximately 02:30 on 8 February, no significant nursing care. He was later found kneeling by his bedside having suffered a head injury which led to his death on 10 February at 13:45.
Ghosh was admitted on the morning of 9 February 2024 suffering with delirium, electrolyte imbalance, infection and a heart condition. 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 not risk assessed by nursing staff until almost midnight.
In the early hours of 10 February, 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 one-to-one 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 on 11 February.
The coroner stated: “In each case frail elderly men were left to wait for very many hours being cared for by their families, rather than supported by nurses and treated in proper bed spaces. When their families left during the night, they both fell as they were unsupervised, sustaining injuries that led to their deaths.”
Hospital made changes but ‘risk remains’
Following the deaths, St George’s implemented several measures including allocating more nurses to A&E, diverting frail patients to an elderly care unit, training and auditing on risk assessments, and making health care assistants available to help care for patients who need one-to-one supervision.
The hospital has also expanded its Same Day Emergency Care unit and introduced a new departure lounge to free up beds for people who need overnight admission, a spokesperson told Putney.news.
However, the coroner’s report notes that evidence taken during the inquest showed that “despite all these measures many shifts in A&E are still exceptionally busy” and staff report conditions causing “distress to the staff attempting to manage impossible situations where demand clearly exceeds available resource in terms of staff and facilities.”
The coroner raised four specific concerns with the Health Secretary: A&E departments have insufficient staff to manage demand during busy periods, meaning nursing risk cannot be managed without relying on families; workplace stress on A&E staff may cause them to leave the profession, worsening shortages; local hospitals have implemented actions within their power but these have been insufficient, requiring central government consideration; and it is unsafe for families to leave loved ones unsupervised in overcrowded A&E departments.
Three weeks after the coroner’s report was published, the hospital issued a statement on 4 January warning of “extreme pressures” from what it called a “triple threat” of cold weather, winter viruses and high numbers of vulnerable patients requiring specialist care. As of that Sunday, 45 beds across St George’s, Epsom and St Helier hospitals were occupied by patients with flu alone, whilst other beds and wards had been closed due to flu and norovirus.
Elaine Clancy, Group Chief Nurse, said: “It’s been a bleak start to the new year as, like other hospitals up and down the country, we’re seeing some very sick patients come to our hospitals – and the cold weather and winter illnesses are having a real impact.”
Questions about governance and transparency
St George’s Hospital is currently rated “requires improvement” by the Care Quality Commission following a November inspection that found a “toxic culture” with staff too scared to report safety concerns. The hospital has also refused to release information about how long it knew of serious errors by a senior emergency nurse, and admitted in December that its computer system has been getting pregnancy risk scores wrong for ten months.
The coroner’s report was not mentioned in the 182 pages of public papers for the hospital trust’s Board meeting on 8 January. The Health Secretary’s response is due within 56 days of the report’s publication on 17 December.
When asked whether the report was discussed at Wednesday’s Board meeting and when the response will be submitted, St George’s did not answer. The trust also declined to say how many shifts in the past six months have operated above safe staffing levels in A&E.
The hospital told Putney.news both falls were reported to the Care Quality Commission. The trust is required to respond to the Health Secretary by 11 February 2026.
The hospital is under severe financial pressure, with debts exceeding £100 million largely due to expensive Private Finance Initiative commitments. These pressures have led to service closures at Queen Mary’s Hospital in Roehampton, where residents have been forced to travel further for treatment previously available locally.
If you have information about patient safety at St George’s Hospital, contact news@putney.news.
