Prevention of Future Deaths reports · 2013
Regulation 28 report to prevent future deaths, reference 2013-0230, written 16 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 | 16 Sep 2013 |
|---|---|
| Reference | 2013-0230 |
| Deceased | George Renshaw Brown |
| Coroner | John Pollard |
| Coroner area | Manchester South |
| Category | Care Home Health 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.
ANNEX A 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. Clinical Commissioning Group 2. Fentons Solicitors 3. Bromleys Solicitors 4 jaytield Care Home 5. Trafford Borough Council © Care Quality Commission [1 | CORONER am John S. Pollard, Senior Coroner, for the coroner area of Manchester South. | 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 1 March 2013 | commenced an investigation into the death of George Renshaw Brown who was born on 13 January 1925 and the investigation concluded at the end of the Inquest on 30 August 2013. The conclusion of the Inquest was that the deceased died from 1a) Pneumonia due to 1b) Cervical spine fracture and under Part II: Acute on chronic bilateral cerebral haematoma and dementia and the conclusion reached by me was that of Accidental Death. [4 | CIRCUMSTANCES OF THE DEATH On Sunday 17 February 2013 the deceased, who was a resident at Mayfield Care Home, left the premises via a fire door and fell down some concrete steps. He fractured his cervical spine and thereafter developed pneumonia leading to his death. 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 is as follows. — (1) There is clear evidence given that Mr Brown was placed, properly, at Mayfield Care Home and that Mayfield Care Home were looking after him within the capabilities of that type of establishment. It soon became apparent to the Manager of that Care Home that they were unable to meet the needs of Mr Brown’s advancing dementia and whilst she brought this to the attention of the appropriate authorities nonetheless it took several months to have him moved to a suitable alternative accommodation. There seemed to be no or no proper and efficient system in place for a speedy re-assessment and transfer of patients whose condition is deteriorating rapidly. ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and | believe you and your organisation have the power to take such action. —t B YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 11 November. |, 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. Date: D BY CORONER COPIES and PUBLICATION | have sent a copy of my report to the Chief Coroner and to the following Interested Persons: namely the solicitors for the family of the deceased, to Mayfield Care Home, the Care Quality Commission and to the Local Adult Safeguarding Board. | have also sent it to Trafford Borough Council 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. nee | Kot
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