Prevention of Future Deaths reports · 2013
Regulation 28 report to prevent future deaths, reference 2013-0246, written 27 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 | 27 Sep 2013 |
|---|---|
| Reference | 2013-0246 |
| Deceased | Rose Jean Coles |
| Coroner | Maria Voisin |
| Coroner area | Avon |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| Organisation named | Bristol NHS Foundation Trust |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
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)
NOTE: This form is to be used after an inquest.
REGULATION 28 REPORT TO PREVENT FUTURE DEATHS
THIS REPORT IS BEING SENT TO:
John Woolley - Chief Executive
University Hospitals Bristol NHS Foundation Trust
Trust Headquarters
Marlborough Street
Bristol
BS1 3NG
1 | CORONER
iam Maria Voisin, Senior Coroner, for the area of Avon
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.
(HYPERLINKS)
3 | INVESTIGATION and INQUEST
On 23rd November 2012 | commenced an investigation into the death of Rose Jean
COLES, Aged 1 month . The investigation concluded at the end of the inquest on 12"
September 2013. The conclusion of the inquest was
{a Congenital heart disease (operated)
CONCLUSION - Rose Jean Coles died due to natural causes. Her death was
attributed to the effects of complex congenital heart disease which she had
received treatment for.
4 | CIRCUMSTANCES OF THE DEATH
Rose Coles was born prematurely at 34 weeks gestation on 4" October 2012, she had
congenital heart disease and received treatment for this. She died at 09:50 hours on 13"
November 2012 at the Bristol Royal Hospital for Children.
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. —
Evidence was given about the communication between the neonatal intensive care unit
and the cardiac unit. Concerns were raised that the cardiac unit were not suited to caring
for premature babies and that a protocol or checklist or better communication between
NICU and cardiac unit would be helpful to assist the doctors and indeed the nurses in
caring for a premature baby on the cardiac ward.
6 | 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.
7 | YOUR RESPONSE
You are under a duty to respond to this report within 56 days of the date of this report,
namely by Friday 22"4 November. I, 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, namely i 2nd to the LOCAL
SAFEGUARDING BOARD (where the deceased was under 18)].
| 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.
27" September 2013 [SIGNED BY CORONER]
.
1 response published against this report on judiciary.uk. A response is a body's written reply to the coroner's concerns; publication is at the discretion of the Chief Coroner's office, so an absent response does not mean nobody replied.
University Hospitals Bristol NHS|
NHS Foundation Trust
Trust Headquarters
Marlborough Street
Bristol, BS4 3NU
Tel: 0117 342 3720
Web-site: www.uhbristol.nhs.uk
RW/iyq
25 October 2013
ME Voisin
Her Majesty's Senior Coroner for the Area of Avon
The Coroner's Court
The Courthouse
Old Weston Road
Flax Bourton
BS48 1UL
Dear Mrs Voisin
Regulation 28 Report Ref 00231/20012 and Ref 03754/2012
Further to the recent inquests, into the deaths of Jared McDowall and Rose Coles, please find attached a
composite action plan addressing the matters of concern addressed within the two Regulation 28 Reports
issued to the Trust on the 1st October 2013. The Trust is confident that the actions described, many of
which are already in hand, will address the concerns expressed and mitigate the risk identified of future
deaths attributable to these factors. The action plan will be monitored through the Trust’s governance
procedures to ensure its full implementation.
Please do not hesitate to contact me if you require any further information.
Yours sincerely
(OIA,
Robert Woolley
Chief Executive
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* University Hospitals Bristol NHS Foundation Trust
0117 923 0000 Minicom 0117 934 9869 www.uhbristol.nhs.uk
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