Prevention of Future Deaths reports · 2013
Regulation 28 report to prevent future deaths, reference 2013-0266, written 21 Oct 2013. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 21 Oct 2013 |
|---|---|
| Reference | 2013-0266 |
| Deceased | Lucy Kilvert |
| Coroner | Robin John Balmain |
| Coroner area | Black Country |
| 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.
Robin J. Balmain
H.M. CORONER
Date:
Smethwick Council House
High Street
Smethwick
West Midlands
B66 3NT
ao Tel: 0845 352 7483
BLACK COUNTRY CORONER’S DISTRICT Fax: ofa 569 5084
(SANDWELL ¢ DUDLEY * WALSALL ¢ WOLVERHAMPTON
E-mail:
Metropolitan Borough Councils) barbara_powles@sandwell.gov.uk
elaine_huckfield@sandwell.gov.uk
15 October 2013 Our Ref: RJB/BAP Your Ref:
REGULATION 28 REPORT TO PREVENT FUTURE DEATHS
THIS REPORT IS BEING SENT TO:
National Institute for Health & Clinical Excellence,
Level One
City Tower
Piccadilly Plaza
Manchester
M1 4BD
1.
CORONER
Robin John Balmain the Senior Coroner for the Black Country Coroners
Jurisdiction
CORONER’S LEGAL POWERS
I 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.
INVESTIGATION AND INQUEST
On 19 June 2013 I commenced an investigation into the death of Lucy
KILVERT. The investigation concluded at the end of the inquest on 16th
October 2013. The conclusion of the inquest was that death was due to an
accident.
CIRCUMSTANCES OF THE DEATH
The deceased was taken to hospital on 14' June 2013 having suffered a fall at
home on 10 June 2013 and subsequently deteriorating. She had hit her head
in the fall and was on blood thinning medication. She was aged 84 at the time.
CORONERS CONCERNS
This Office is open Monday to Thursday 8am to 4pm. Friday 8am to 3pm
H.M. CORONER
21 October 2013 Continuation
The MATTERS OF CONCERN are as follows, namely that Mrs. Kilvert was
not initially at the hospital given a CT scan of the head. It was not performed
until about 8 hours after presentation at hospital and revealed an intracranial
bleed. The medical cause of death was :-
la) Intracranial bleed,
I Chronic Kidney Failure
Hypertension
Heart Valve Replacement.
As it turned out neurological intervention would not have been appropriate
even if a brain bleed had been discovered immediately. I was told by the
consultant in emergency medicine who gave evidence, that although the NICE
Guidelines were considered, the clinical judgment of the senior house officer
who saw her initially was that there was no reason to suspect a bleed,
although the consultant said that his judgment may have been different. The
consultant felt that the Guidelines possibly insufficiently emphasised the
significance of blood thinning medication in elderly people who had had a fall
when considering whether a CT scan of the head was necessary, albeit that
eventually the matter was a question of clinical judgment.
5 ACTION SHOULD BE TAKEN
In my opinion action should be taken to prevent future deaths and I believe
you have the power to take such action.
I would respectfully invite you to consider whether further consideration of
the Guidelines is appropriate.
YOUR RESPONSE
You are under a duty to respond to this report within 56 days of the date of
the report, namely by 17tt December 2013.
COPIES and PUBLICATIONS
I have sent a copy of my report to the Chief Coroner and to the following
interested Persons :
H.M. CORONER
21 October 2013 Continuation
(a) The Medical Director, Russells Hall Hospital.
os
Iam 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.
RJ. Balmain
H.M. Senior Coroner
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