Prevention of Future Deaths reports · 2013
Regulation 28 report to prevent future deaths, reference 2013-0200, written 30 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 | 30 Aug 2013 |
|---|---|
| Reference | 2013-0200 |
| Deceased | Jessica Ashton-Pyatt |
| Coroner | ARW Forrest |
| Coroner area | South Lincolnshire |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | none published |
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AR W Forrest um, rrcp, rrcpath GMC Number: 1333523 Her Majesty's Senior Coroner for South Lincolnshire REGULATION 28: REPORT TO PREVENT FUTURE DEATHS (1) NOTE: This form is to be used after an inquest. '| THIS REPORT IS BEING SENT TO: 1. Ms Jane Lewington, Chief Executive, United Lincolnshire Hospitals REGULATION 28 REPORT TO PREVENT FUTURE DEATHS | = eee 1 | CORONER | am ARW 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. | On 2™ November 2012 | commenced an investigation into the death of Jessica Florence Ashton-Pyatt, Age 14. The investigation concluded at the end of the inquest on 30! August 2013. The conclusion of the inquest was spontaneous rupture of the stomach of uncertain cause; verdict was natura! causes. INVESTIGATION and INQUEST 4 | CIRCUMSTANCES OF THE DEATH On 28th October 2012 Jessica became acutely unwell. On admission to the Accident and Emergency Unit at Pilgrim Hospital she was in extremis. Resuscitation attempts were unsuccessful. Post mortem showed her cause of death to be a ruptured stomach of uncertain, but natural cause. 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. — The response of the staff to Jessica's care on admission was unco-ordinated, with the immediate care being delivered by an SpR in anaesthetics and two EMAS paramedics. There was initially no consultant leadership of Jessica's care. The defibrillator in the resuscitation bay was not charged and no defibrillation pads were initially available. 6 | ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and | believe you have the power to take such action. a Unit 1, Gilbert Drive, Endeavour Park, Boston PE21 7TQ Tel: 01522 553374 Fax: 01522 516717 Email: HMCoroner_Southlincolnshire@lincolnshire.gov.uk AR W Forrest iw, rrcp, FRcPath GMC Number: 1333523 Her Majesty's. Senior Coroner for South Lincolnshire YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 24" 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 he Chief Coroner, and to the following Interested Pa hn oss to the Local Safeguarding Board for Lincolnshire and Staffordshire (where the deceased was under 18)]. | have also sent it toa , Risk Manager, United Lincolnshire Hospitals and] Nurse Consultant, Accident and Emergency Unit, Pilgrim Hospital 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. 30/08/2013 ARW Forrest (HM Senior Coroner for South Lincolnshire) Werk Unit 1, Gilbert Drive, Endeavour Park, Boston PE21 7TQ P|
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