Prevention of Future Deaths reports · 2013
Regulation 28 report to prevent future deaths, reference 2013-0195, written 23 Sep 2013. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 23 Sep 2013 |
|---|---|
| Reference | 2013-0195 |
| Deceased | Yvonne Sydney Annie Perry |
| Coroner | Tom Osborne |
| Coroner area | Milton Keynes |
| Category | Hospital Death (Clinical Procedures and medical management) 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.
The Office of Tom Osborne
Her Majesty’s Senior Coroner for Milton Keynes
Civic Offices, 1 Saxon Gate East, Milton
Mr Joe Harrison Keynes, MK9 3EJ
Chief Executive
Our Ref: TRO/FT
Milton Keynes General Hospital anne
Standing Way Your Ref: 0000000
Eaglestone Reply To: Coroner
Milton Keynes
MK6 5LD Direct Line: fF
E-Mail:
23 September 2013
Dear Sir,
Re: Regulation 28 Report to Prevent Future Deaths
|, as the Senior Coroner for the Coroner Area of Milton Keynes, 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.
On 4th February 2013, | commenced an investigation into the death of Yvonne
Sydney Annie Perry. The investigation concluded at the end of the inquest on 20"
September 2013. The conclusion of the inquest was a narrative conclusion:
Yvonne Sydney Annie Perry fractured her left hip following a fall at
home on 17th December 2012. The possibility of a fracture was
recognised by the radiologist on 19th December 2012 but the radiology
report was not acted upon until 4th January 2013 when she was
readmitted to Milton Keynes General Hospital unable to weight bear.
She developed a severe urinary tract infection and died of sepsis on
2nd February 2013.
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) That the x-ray taken of Mrs. Perry’s hip, reported on by the consultant
radiologist on the 19" December 2012, was not acted upon until the 3”
January 2013. It was recognised that the Hospital “do not have a robust
process for tracking that the emergency department consultants have looked
at the radiology reports.” Without such a system | believe further deaths may
occur in the future.
(2) The GPs who attend the Windsor Intermediate Care Unit do not have access
to the electronic hospital notes and records and those witnesses from WICU
who attended the inquest considered that such access would improve the
care afforded to patients. Similarly without access to the patients notes further
deaths may occur in the future.
In my opinion action should be taken to prevent future deaths and | believe you have
the power to take such action.
You are under a duty to respond to this report within 56 days of the date of this
report, namely by 18" November 2013. 1, 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.
| have sent a copy of my report to the Chief Coroner and to the family as properly
Interested Persons .| have also sent it to Care Quality Commission 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.
| await hearing from you va ew response.
{
Yours sincerely
Tom Osborne
Her Majesty’s Senior Coroner for Milton Keynes
This report is being sent to:
e Family of Mrs Perry
e Chief Coroner
e Care Quality Commission
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