The home assessment took place after she had gone home. Grab rails had not been fitted, and a double bed had not yet been swapped for a single one to make it easier to move around the bedroom. A week after discharge, shortly before the work was due, she had an unwitnessed fall in her bedroom. She suffered a head injury, never regained consciousness, and died at the hospital on 23 November.
Guy Davies, assistant coroner for Cornwall and the Isles of Scilly, recorded a conclusion of accident. He could not establish why she fell, or whether the missing adaptations caused or contributed to the fall. He found that they could have been fitted if there had been enough notice before discharge.
His report, dated 10 August 2026, was sent to the Secretary of State for Health and Social Care. He warned that rapid discharge events put heavy pressure on hospital and community staff and raise the risk of patients leaving without adequate care, including aids and adaptations at home. He identified the root cause as "inadequate social care provision", which he described as ongoing. At times up to 20 per cent of the hospital’s patients had no reason to remain there, leaving beds blocked, emergency departments crowded, patients treated in corridors and ambulances queuing outside.
Davies had raised the same root cause in March 2024, after the death of Patricia Eyken, 93. She called 999 in the early hours of 13 September 2023 with chest pain running down her left arm. The ambulance took two hours and 37 minutes to arrive. Davies found that the delay "more likely than not contributed" to her death "by preventing the administration of life saving treatment." He traced the delay to a failure outside the ambulance service: patients fit to leave hospital were stuck on wards for lack of domiciliary and residential care, so ambulance crews waited to hand over. In 2023 those handover delays cost 35,583 hours at Treliske alone.
The department replied on 3 July 2024, in a letter signed by Helen Whately, then the care minister. It cited "£1 billion" invested "this year through the Discharge Fund", a £40 million fund for the councils facing the greatest urgent and emergency care pressures, £3 million for Cornwall Partnership NHS Foundation Trust in 2023/24, and an average fall of almost 23 minutes in ambulance handover times between October 2023 and May 2024.
National safety investigators had already called for "an immediate strategic national response" to the harm caused by patients being unable to move through hospitals. The department accepted that recommendation in October 2022. On 1 October 2024, 45 days before Pamela was discharged, it updated its response. It said arrangements were "now in place at system level through System Coordination Centres", that intermediate care capacity and demand plans would be kept "under regular review", and that it would focus on "minimising delays in agreeing people’s post discharge needs" for people with complex needs.
The investigators also recommended a patient safety accountability framework spanning health and social care. In November 2023 the department said existing regulators and oversight bodies should make accountability work across organisations. The investigators recorded that this response "did not meet the intent of the safety recommendation" and asked for clarification. In October 2024 the department kept its position and pointed to a review by Dr Penny Dash and to work on safety management systems. No assessment of that second response has been published.
Pamela was discharged under Royal Cornwall Hospitals NHS Trust’s chief executive, Steve Williamson, and its chair, Dr Mairi McLean, who was succeeded by David Allen in January 2025. Wes Streeting was Health Secretary from July 2024 to May 2026. Yvette Cooper has held the post since 20 July 2026 and received the coroner’s report.
The department’s response was due by 5 October 2026. When the report was published on 13 October, no response had been published.