Prevention of Future Deaths reports · 2013
Regulation 28 report to prevent future deaths, reference 2013-0360, written 23 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 | 23 Oct 2013 |
|---|---|
| Reference | 2013-0360 |
| Deceased | John Lansdowne |
| Coroner | Paul Kelly |
| Coroner area | North Lincolnshire & Grimsby |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
Regulation 28: Prevention of Future Deaths report
John Frank Henry LANSDOWNE (died 19.05.13)
THIS REPORT IS BEING SENT TO:
1. Ms Wendy Wallace
Chief Executive
Camden & Islington NHS Foundation Trust
St Pancras Hospital
4 St Pancras Way
London NW1 0PE
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 22 May 2012, my assistant coroner, Selena Ruth Lynch, commenced
an investigation into the death of John Frank Henry Lansdowne, aged 62.
The investigation concluded at the end of the inquest on 22 October
2013. The jury returned a narrative conclusion, which I have attached.
4
CIRCUMSTANCES OF THE DEATH
John Lansdowne was diagnosed with schizophrenia in 1980. He had
been cared for by local psychiatric in patient and out patient services for
at least eighteen years prior to his death.
1
On Tuesday, 15 May 2012, he was admitted to St Pancras Hospital under
s3 of the Mental Health Act, at the time talking a great deal about taking
his life. He had in 2010 and 2011 jumped in front of trains, sustaining
very significant injuries on each occasion.
At 10.30pm on Friday, 18 May 2012, he was found submerged in the
bath. Cardiopulmonary resuscitation was attempted and he was taken by
ambulance to University College Hospital, but he died shortly thereafter.
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. The jury found that the times observations of Mr Lansdowne took
place in the 45 minutes preceding his discovery were unclear,
despite a nursing observation record setting these out.
2. There was confusion regarding the retrieval of the entirety of the
medical/nursing records after Mr Lansdowne’s death, and one
observation sheet was never recovered.
3. At inquest, there was a lack of consistency in the understanding of
nursing staff on Laffan Ward at St Pancras Hospital, as to the
exact requirements of intermittent observations when a patient is
bathing.
4. Mr Lansdowne died in the bath, it is possible as a result of
drowning. Mr Lansdowne’s family explained at inquest that in
other hospitals where he had been treated, only walk in showers
are used.
6
ACTION SHOULD BE TAKEN
In my opinion action should be taken to prevent future deaths and I
believe you and Camden & Islington NHS 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 18 December 2013. I, the coroner, may extend
2
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 following.
HHJ Peter Thornton QC, the Chief Coroner of England & Wales
, John Lansdowne’s parents
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
he believes may
interest. You may make
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
23.10.13
3
. . 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 DEATI:;IS THIS REPORT IS BEING SENT TO: 1. North East lincolnshire Council, 2 Origin Way, Grimsby. , Principal Traffic Engineer, Highways & Transport, 1 . CORONER I am Paul Kelly, senior coroner, for the coroner area of North lincolnshire and Grimsby. . 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 '1;' 3 (InvestiQations) ReQulations 2013. INVESTIGATION and INQUEST On 11.1.13 I commenced an investigation into the death of lynne Dring age 52 years. The investigation concluded at the end of the inquest on ,17.12.13. The conclusion of the inquest was head injury due to road 4 5 traffic collision. CIRCUMSTANCES OF THE DEATH The deceased was crossing A 1098 Taylors Avenue, Cleethorpes at a roundabout controlled junction known as Hewitts Circus when she was struck by a car exiting the roundabout. 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) Street furniture, notably a central illuminated bollard may obstruct/interfere with motorists view. (2) White lines indicating an Elephant crossing are non-prescribed and may induce pedestrians to believe they have priority. 6 ACTION SHOULD BE TAKEN . In my onion action should be taken to prevent future deaths and I believe your organisation have the power to take such action by reviewing the street furniture and elephant crossing at this location. ; . 1i;.. , , '... . --,.~_'~L-C .:' - \ i \ f ( ; ! , -" t ! . ':c .. . . 7 YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report. '0, , 8 COPIES AND PUBLICATION I have sent a copy of my report to the Chef Coroner and to the family of the deceased. . 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 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. . \ , , , i I \, i . ." t ~ ~C, "" 'Yi l ".' 'ciS::;' ;-. . ~c:" ~ 1::,' E c,~ . " 9 DATE )o~ '\.,..)\,) SIGNED BY CORONER f~ \~. . " f . . '~t C'~"( ~c~~;.::j;:-,,;;,;, c" -
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.
.' 0;" .~;(; ""- ~ Coroners Unit 3 0 J.'.N 2 " 011 NO~ rl~t,JLNSHIRE Balfour Beatty co U N C I L www.nelincs.gov.uk WorkPlace Working in Partnership Mr P Kelly H.M Coroner Cleethorpes Town Hall Knoll Street Cleethorpes North East Lincolnshire DN358LN 27 January 2014 Dear Mr Kelly, ~~~~t=::,,:;;:~,,:::,,;;;~, '~""c..,-c"',"C"~"-'- c " Our Ref.: AI300 Your Ref.: PK/JSG PN No.: When calling please ask for: Direct line telephone number: e-mail address: traffic@nelincs.gov.uk . '" FATAL RTC - 9TH JANUARY 2013 A1098 HEWITTS CIRCUS ROUNDABOUT, CLEETHORPES . I refer to your letter of 30th December 2013 in relation to the above. The concerns expressed in the Regulation 28 report are as follows ~(1 ) Street furniture, notably a central i1tuminat~~ bo11ard may obstructlinterfere- . with motorists view. (2) White line indicating an Elephant crossing are non-prescribed and may induce pedestrians to believe they have priority. To these you have suggested that action should be taken to prevent future deaths by reviewing the street furniture and elephant crossing at the roundabout. I can inform you that it is intended to replace the illuminated bollards at the roundabout with non-illuminated bollards. These are not significantly smaller that the bollards currently present but in replacing them a location within the central refuge will be chosen so as to offer the best guidance to motorist whilst avoiding restricting visibility to or of a pedestrian attempting to cross the roads. With regard to the WBM 294 (elephants footprints) road markings, all sites where these have been installed have been identified; some 17 sites in total. A program of removal has been complied with the intention of removing markings at 10 sites being the priority. The Hewitt's Circus roundabout is in this "top 10" priority listing. Yours sincerely, Principal Traffic Engineer .
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