Prevention of Future Deaths reports · 2013
Regulation 28 report to prevent future deaths, reference 2013-0322, written 3 Dec 2013. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 3 Dec 2013 |
|---|---|
| Reference | 2013-0322 |
| Deceased | Agostino Costa |
| Coroner | Mary Hassell |
| Coroner area | Inner North London |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| Organisation named | Whittington Hospital NHS Trust |
| 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: Prevention of Future Deaths report
Agostino COSTA (died 12.05.13)
THIS REPORT IS BEING SENT TO:
1. Dr Yi Mien Koh
Chief Executive
The Whittington Hospital NHS Trust
Magdala Avenue
London N19 5NF
1
CORONER
I am: Coroner ME Hassell
Senior Coroner
Inner North London
St Pancras Coroner’s Court
Camley Street
London N1C 4PP
2
CORONER’S LEGAL POWERS
I make this report under the Coroners and Justice Act 2009,
paragraph 7, Schedule 5, and
The Coroners (Investigations) Regulations 2013,
regulations 28 and 29.
3
INVESTIGATION and INQUEST
On 12 May 2013, one of my predecessor coroners, Sean McGovern,
commenced an investigation into the death of Agostino Costa, aged 80. I
concluded this investigation at the end of the inquest on 28 November
2013.
4
CIRCUMSTANCES OF THE DEATH
I concluded that Mr Costa died as a consequence of a terminal disease,
though his death was hastened by an accidental fall in hospital at 6.40pm
on Sunday, 12 May 2013.
I recorded a medical cause of death of:
1a acute on chronic subdural haemorrhage
1b minor trauma in an individual with chronic idiopathic myelofibrosis.
1
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. There was confusion among the staff as to whether Mr Costa was
classified as red (high risk) or green (low risk) in terms of falls.
2. There was confusion among the staff as to whether a patient
walking with a frame presents a high risk of falls.
3. There was confusion among the staff as to whether a patient with
myelofibrosis and blood transfusions presents a high risk of falls.
This confusion was also present in the hospital root cause analysis
conducted after Mr Costa’s death.
4. The junior doctor present did not know how to deal with a patient
post fall on the ward, though he had dealt with patients in the
emergency unit who had fallen in the community. He had not
attended the hospital training seminar on falls.
5. The hospital root cause analysis was not shared with all relevant
members of staff, though it was signed off at the beginning of
August. Thus learning points from it were completely lost to some.
I heard that a great deal of work is being done in your trust to attempt to
prevent falls and appropriately to treat patients when falls have occurred,
but attendance at one of the monthly seminars run by the lead doctor for
falls is not mandatory for all staff.
6
ACTION SHOULD BE TAKEN
In my opinion, action should be taken to prevent future deaths and I
believe that you and your 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 28 January 2014. I, the coroner, may extend the
period.
2
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 following.
HHJ Peter Thornton QC, the Chief Coroner of England & Wales
son of Agostino Costa
I 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
interest. You may make
he believes may
representations to me, the Senior Coroner, at the time of your response,
about the release or the publication of your response by the Chief
Coroner.
it useful or of
find
9
DATE SIGNED BY SENIOR CORONER
03.12.13
3
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