Prevention of Future Deaths reports · 2013
Regulation 28 report to prevent future deaths, reference 2013-0288, written 10 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 | 10 Oct 2013 |
|---|---|
| Reference | 2013-0288 |
| Deceased | James Edward Mansfield |
| Coroner | Mrs Cheney |
| Coroner area | Cambridgeshire (South and West) |
| Category | Community health care |
| Source | judiciary.uk record · original PDF |
| Responses published | none published |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
REGULATION 28 REPORT ON ACTION TO PREVENT FUTURE DEATHS
THIS REPORT IS BEING SENT TO:
1. Nuffield Road Medical Centre
2
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.
3
INVESTIGATION and INQUEST
On 14th March 2013 I commenced an investigation into the death of James Edward
Mansfield whose date of birth was 15 February 1943. The investigation concluded at the
end of the inquest on 10 October 2013. The medical cause of death was:
1a) Right haemothorax
1b) Multiple rib fractures
1c) Fall
2) Atrial fibrillation with anticoagulation
Hypertensive heart disease
Hepatic cirrhosis
The conclusion of the inquest was that Mr Mansfield died as a result of bleeding into his
chest due to rib fractures sustained in a fall, coupled with treatment with warfarin.
4
CIRCUMSTANCES OF THE DEATH
Mr Mansfield had a long history of lung related complications and had multiple
occurrences of pneumonia. He was on warfarin. On 25 February2013 he fell at this
home. He saw the GP who referred him to the x-ray department at Addenbrookes. An x-
ray showed four displaced rib fractures. He was reviewed in the A+E where he said he
was comfortable and he was discharged to the care of his GP, with a leaflet. On 27
February
called the GP advising of Mr Mansfield’s pain and she
requested stronger painkillers. These were prescribed but he was not seen. The
discharge summary was received by the GP Surgery on 28th February and was
reviewed on 6 March. On 8 March Mr Mansfield called for the GP. He was admitted to
Addenbrookes and a chest x-ray revealed a large right haemothorax. Mr Mansfield
passed away at 18.55 on 9 March 2013.
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 could 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) Mr Mansfield had an xray and was discharged from Addenbrookes Hospital on
25 February. You have arranged that that the hospital post discharge letters to
your surgery. This was not received received until 28th February 2013 by which
time Mrs Mansfield had called requesting stronger pain killers. The discharge
summary was only reviewed by a doctor on 6 March. You stated that only if a
patient was admitted to hospital would their discharge letter get prompt
attention. There was no apparent method for differentiating between discharge
summaries which involved serious injuries and those which did not.
(2) When
telephoned the surgery, complaining of Mr Mansfield’s
pain, strong pain killers were prescribed but he was not seen despite a long
history of lung and chest complaints, multiple rib fractures and treatment with
warfarin.
6
ACTION SHOULD BE TAKEN
In my opinion action should be taken to prevent future deaths and I believe that you
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 3rd January 2014. 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.
8
COPIES and PUBLICATION
I have sent a copy of my report to the Chief Coroner and to the following Interested
Persons, Addenbrookes Hospital and
Similarly, you are 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.
9
[DATE] [SIGNED BY CORONER]
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