Prevention of Future Deaths reports · 2013
Regulation 28 report to prevent future deaths, reference 2013-0228, written 11 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 | 11 Sep 2013 |
|---|---|
| Reference | 2013-0228 |
| Deceased | Caroline Lee |
| Coroner | Sean McGovern |
| Coroner area | Coventry |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | none published |
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REGULATION 28: REPORT TO PREVENT FUTURE DEATHS (1) NOTE: This form is to be used after an inquest. REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: 1. 2. Chief Executive - University Hospital Coventry & Warwickshire 1 | CORONER | am S McGovern, senior coroner, for the coroner area of Coventry 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 24 June 2013 | commenced an investigation into the death of Caroline LEE 49 years old. The investigation concluded at the end of the inquest on 11 September 2013. The conclusion of the inquest was a Narrative Verdict (Copy attached). 4 | CIRCUMSTANCES OF THE DEATH See Narrative Verdict 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) failure of the medical staff to recognise the significance of the potassium results (2) failure of the laboratory to inform the Ward staff of the abnormal potassium results 6 | ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and | believe you as Chief Executive of the Trust have the power to take such action. 7 | YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 6" October 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. COPIES and PUBLICATION | have sent a copy of my report to the Chief Coroner and to the following interested Persons (2) EN (partner of Ms Lee), “oo (sister of Ms Lee). tam 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. 11” September 2013 Vo. ahs Senior Coroner S McGovern wlANW Vv 4 an V AW
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