Prevention of Future Deaths reports · 2013
Regulation 28 report to prevent future deaths, reference 2013-0178, written 8 Aug 2013. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 8 Aug 2013 |
|---|---|
| Reference | 2013-0178 |
| Deceased | Dimitar Shtarbov |
| Coroner | Alexander R W Forrest |
| Coroner area | South Lincolnshire |
| Category | Accident at Work and Health and Safety related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | none published |
Text recovered by OCR from a scanned PDF. OCR is imperfect: check anything you rely on against the source PDF. Reproduced verbatim, including the scan's own layout.
REGULATION 28: REPORT TO PREVENT FUTURE DEATHS (1)
REGULATION 28 REPORT TO PREVENT FUTURE DEATHS
THIS REPORT IS BEING SENT TO:
1. Po Governing Body Consultant in Public Health, South
Lincolnshire Clinical Commissioning Group
Clinical Leader and Chair of Boston Area Locality, East
Lincolnshire Clinical Commissioning Group
1 | CORONER
| am Alexander R W Forrest, senior coroner, for the coroner area of South Lincolnshire.
2 | CORONER’S LEGAL POWERS
| make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009
and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013.
3 | INVESTIGATION and INQUEST
On 20" August 2012 | commenced an investigation into the death of Dimitar
SHTARBOV, born on 18"" August 1984. The investigation concluded at the end of the
inquest on 26" July 2013. The conclusion of the inquest was that the meical cause of
death was 1a Bilateral Pneumothoraces due to 1b Acute Asthma and that this was an
Accident.
4 | CIRCUMSTANCES OF THE DEATH
Dimitar was a Bulgarian seasonal Agricultural worker with a long history of asthma
treated with bronchodilator inhalers, theophylline and long acting injected corticosteroids
in Bulgaria. He did not declare this history when he completed pre-employment
questionnaires. He arrived in Lincolnshire for his second year of seasonal work on 6"
July 2012. He became ill in early August and attended the A&E department at Pilgrim
Hospital 9" & 10" August 2012. Clinical staff at the hospital did not learn of his history
of Asthma. He was treated for a wheezy chest infection with antibiotics and a salbutamol
inhaler. On the 11™ of August, his condition deteriorated and his fellow workers brought
him to the A&E department at Pilgrim Hospital. He was in cardiac arrest on his arrival
and recuscitation attempts were unsuccessful
5 | CORONER’S CONCERNS
During the course of the inquest the evidence revealed matters giving rise to concern. In
my opinion there is a risk that future deaths will occur unless action is taken. In the
circumstances it is my statutory duty to report to you.
The MATTERS OF CONCERN are as follows. —
(1) Evidence was presented to the effect that the majority of seasonal agricultural
workers do not know how to access General Practitioner Services and indeed are not .
aware of the service. They often access primary health care at need via the accident
and emergency department
(2) They are often not aware of either the 999 service or the 111 service
(3) They are often not aware that they are entitled to GP services in the UK, without
charge, for the management of chronic medical conditions
(4) Dimitar obtained salbutamol inhalers (labelled in both English and Bulgarian — the
latter in Cyrillic Script) and injectable long acting beclomethasone (labelled in Cyrillic
script) by post from Bulgaria, with extra supplies being posted to him when he became
ill. The evidence as to whether or not these medicines were shown to A&E staff was
inconsistent. | was informed in Court that it is very common for seasonal workers with
chronic conditions to have what would be prescription only medicines in the UK posted
to them from home where such medicines can often be purchased freely without
prescription.
ACTION SHOULD BE TAKEN
In my opinion action should be taken to prevent future deaths and | believe your
organisations have the power to take such action.
YOUR RESPONSE
You are under a duty to respond to this report within 56 days of the date of this report,
namely by 4" October 2013. |, the coroner, may extend the period.
Your response must contain details of action taken or proposed to be taken, setting out
the timetable for action. Otherwise you must explain why no action is proposed.
COPIES and PUBLICATION
| have sent.a copy of my report to the Chief Coroner and to the following Interested
rec, a Solicitor for the family. | have also sent it La
ational Review of Asthma Deaths, Royal College of Physicians) and Mr Derek
Winter (Coroners Society of England & Wales) who may find it useful or of interest.
| am also under a duty to send the Chief Coroner a copy of your response.
The Chief Coroner may publish either or both in a complete or redacted or summary
form. He may send a copy of this report to any person who he believes may find it useful
or of interest. You may make representations to me, the coroner, at the time of your
response, about the release or the publication of your response by the Chief Coroner.
8™ August 2013 l { 4 uird—
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