Prevention of Future Deaths reports · 2013
Regulation 28 report to prevent future deaths, reference 2013-0370, written 19 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 | 19 Dec 2013 |
|---|---|
| Reference | 2013-0370 |
| Deceased | Michael Longley |
| Coroner | Rachael Redman |
| Coroner area | Kent (Central & South East) |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| Organisation named | Kent Community Health NHS Foundation 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: REPORT TO PREVENT FUTURE DEATHS
REGULATION 28 REPORT TO PREVENT FUTURE DEATHS
THIS REPORT IS BEING SENT TO:
Ms M Dinwoodie
Chief Executive
Kent Community NHS Trust
The Oast
Unit D
Hermitage Court
Barming Maidstone
Kent ME19 9NT
1
CORONER
I am Rachel Redman, Senior Coroner, for the Coroner area of Central and South East
Kent.
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 17th and 18th October 2013 I commenced an investigation into the death of Michael
Longley. My summary of evidence and conclusion were read at Folkestone Magistrates
Court on 18th December 2013 when the inquest ended. The conclusion of the inquest
was a Narrative Verdict.
4
CIRCUMSTANCES OF THE DEATH
Mr M D Longley had an adverse reaction to Rivaroxaban which was administered after
hip surgery which took place on 071211 at William Harvey Hospital, Ashford. Clexane
was administered on 261211 by the district nurses. He was admitted to William Harvey
Hospital on 311211 with an unrecordable platelet count and died the same day.
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. –
I heard evidence that Integrated Care 24 had difficulties in contacted the District Nursing
Service on 25th December 2011 and I consider that improved methods of both oral and
written communication between IC24 and the district nurses must be put in place.
6
ACTION SHOULD BE TAKEN
I consider the training of District Nurses must now include that a patient should be
examined if symptoms of bleeding have been reported.
7
YOUR RESPONSE
You are under a duty to respond to this report within 56 days of the date of this report,
namely by 12th February 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:-
AVMA
Gordons Partnership
RadcliffesLeBrasseur
Clyde & Co
Berrymans Lace Mawer
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.
9
Date: 19th December 2013 Signed by
H M Coroner
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