Nisren died after falling over while she was an inpatient in hospital. She had been under the care of the neurology service at a different hospital, but their records were (a) extremely limited and (b) only available via Patient Pass rather than as part of her main hospital record. This meant that clinicians at the hospital where she was an inpatient were unaware of her neurological needs, so weren't observing her as they should have been when she fell.