Prevention of Future Deaths reports · 2013
Regulation 28 report to prevent future deaths, reference 2013-0363, written 20 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 | 20 Dec 2013 |
|---|---|
| Reference | 2013-0363 |
| Deceased | Kate Louise Pierce |
| Coroner | John Gittins |
| Coroner area | North Wales (East & Central) |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| 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 REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT !S BEING SENT TO: 1. General Medical Council Regent’s Place, 350 Euston Road, London NW1 3JN 1 CORONER 1am JOHN GITTINS, senior coroner for the coroner area of North wales (East and Central) 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. 3. | INVESTIGATION On the 9" of May 2013 | commenced an investigation into the death of KATE LOUISE PIERCE, Aged 7. The investigation has not yet concluded and the inquest has not yet been heard. 4 | CIRCUMSTANCES OF THE DEATH The deceased is Kate Louise PIERCE (d.o.b. 29/06/2005). Although the matters in question took place on or around the 29" March 2006, Kate eventually died on the 14/03/2013 aged 7 years. No post-mortem examination has been held and Kate’s body has been cremated. The cause of death as per Kate’s death certificate is; Acquired Cerebral Palsy, epilepsy and chronic lung disease complications following Meningitis’ 5 | CORONER’S CONCERNS During the course of the investigation my inquiries 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. — On the 29" of March 2006 Kate was taken into the Wrexham Maelor Hospital where she was examined by a Dr . It appears from the evidence available that he failed to deal correctly with the diagnosis of Kate's condition and furthermore there is a belief that he may have misled the parents of Kate by indicating that he had sought a second opinion from a colleague before discharging her when this was not in fact the case. | understand that enquiries were made previously by the GMC following a complaint against Dr [I but that no action has been taken due to legal action by the Dr in view of the elapse of a relevant time limit. In the course of my current investigation following Kate’s death, a statement has been obtained from a witness namely DAE and _a copy of this is annexed hereto. My view is that this statement casts doubt on aa fitness to practice and this is of grave concern as my understanding is that he currently continues to practice as a GP within my Coroner Area. In view of this | consider that there is a risk of future deaths. ACTION SHOULD BE TAKEN In my opinion urgent action should be taken to prevent future deaths and | believe your organisation has the power to take such action. YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 14" of February 2014. |, 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, the parents of Kate Pierce and to the LOCAL SAFEGUARDING BOARD. | have also sent it to DC! IE of Cheshire Police who may find it useful or of interest. lam 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. DATE SIGNED BY CORONER PATE] 2012. 1% I If GA.
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.
4 February 2014 General Our ref: E1-DHFKTI Medical Council John Gittins 3 Hardman Street Senior Coroner for North Wales (East and Central) oor H.M. Coroner’s Office atari “do e sa acsimile: County Hall Email: gmc@gmc-uk.org eee www.gmc-uk.org uthin LL15 1YN Dear Mr Gittins Re: Investigation touching upon the death of Kate Pierce Thank you for your letter of 20 December 2013 enclosing your Report to Prevent Future Deaths. I am responding as the officer responsible for the Council's fitness to practise work. We have carefully considered your report and in particular, the matters of concern set out in your report. We are aware of Dr J and his involvement in Kate Pierce’ care, as this matter was initially brought to our attention on 27 April 2012. We made preliminary enquiries of the Betsi Cadwalader University Health Board and subsequently received a formal complaint from Mr pn 12 July 2012. We considered the complaint by Mri in accordance with our statutory framework and initially decided to investigate the case although the events at that time were more than five years old. Our statutory rules preclude us from investigating events that are more than five years old unless it is in the public interest in the exceptional circumstances to do So. We were challenged by o i, way of Judicial Review about our decision to investigate the case even though the events were over five years old. Having taken advice from Counsel we decided to concede the Judicial Review and close our investigation. With regard to or i audit, we received and considered a copy of this audit in late 2012. It relates to i practice in 2007 and so was subject to the five year rule. We considered whether to waive the rule and concluded that the concerns raised did not satisfy the criteria for us to waive the rule and no further action was taken. In terms of ii current fitness to practise, we have not received any further complaints about Dr HEE since 2007. Additionally, as part of the process of revalidation of a doctor’s licence to practise, doctors must have a Responsible Officer whose statutory duties include reporting concerns to us, if they call into question a doctor’s current fitness to practise. Our Employer Liaison Advisor who is a senior member The GMC is a charity registered in : Regulating doctors England and Wales (1089278) and Scotland (SCO37750) Ensuring good medical practice of staff working in the region has met regularly with or Responsible Officer who has expressed no concerns about his current practice. All registered doctors are also now required to revalidate their registration in order to keep their licence to practise. Once every five years, the doctor's Responsible Officer will make a recommendation to us as to whether a doctor should be revalidated and keep their licence to practise. Revalidation is aimed at supporting doctors in maintaining high standards, and will also help in identifying any concerns early on so that suitable action can be taken. I hope I have explained why no action by us in this case is proposed and more importantly I have been able to address your concerns about as I would be happy to take your call on this if you feel it would assist. Yours sincerely Director Fitness to Practise Directorate
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