Prevention of Future Deaths reports · 2014
Regulation 28 report to prevent future deaths, reference 2014-0003, written 6 Jan 2014. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 6 Jan 2014 |
|---|---|
| Reference | 2014-0003 |
| Deceased | Chloe Grace Flavell |
| Coroner | Maria Voisin |
| Coroner area | Avon |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| Organisation named | Weston Area Health NHS Trust |
| Source | judiciary.uk record · original PDF |
| Responses published | none published |
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 (1) NOTE: This form is to be used after an inquest. REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: 1. BE (Medical Director) and Mr. N. Wood (Chief Executive) Weston Area Health NHS Trust Grange Road Uphill Weston-super-Mare BS23 4TQ CORONER | am Maria Voisin, Senior Coroner for the area of Avon. 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 and INQUEST On 15" April 2013 | commenced an investigation into the death of Chloe Grace FLAVELL, Aged 3 days. The investigation concluded at the end of the inquest on 18" December 2013. The conclusion of the inquest was: CAUSE OF DEATH la Congenital heart disease (critical aortic valve stenosis with bicuspid aortic valve, small left ventricle and small mitral valve) CONCLUSION Chloe Grace Flavell died of natural causes contributed to by neglect. 4 | CIRCUMSTANCES OF THE DEATH Chioe Flavell became unwell and was taken by her parents to Weston General Hospital on the morning of 3” April 2013 and died there at 14:30 hours. 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. — It became apparent during the evidence that the management of the reception area, i.e. the stage before triage, could add significant delay when assessing someone who was in need of immediate care and treatment especially a child. | therefore indicated at the conclusion of the inquest that | would write to the Trust about the management of the reception area for them to consider whether there ought to be a better system in place to ensure that those needing immediate care and treatment, especially children, are managed in a more appropriate and efficient way to minimise delay and ensure that immediate care and treatment is given ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and | believe your organisation have 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 Monday 3" March 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 the Properly Interested Persons and to the LOCAL SAFEGUARDING BOARD. 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. cs [6" January 2014] [Maria Fvosin —<C_———__| |
Weston Area Health NHS NHS Trust Ref: NG/DLM Date: 13" January 2014 CHIEF EXECUTIVE'S OFFICE General Hospital Private & Confidential Grange Road, Uphill Addressee Only Weston-super-Mare Somerset Avon Coroner BS23 4TQ Coroners Court Old Weston Road Tel: 01934 636363 Direct Line: 01934 647001 Dept Fax: 01934 647176 Website: http://www.waht.nhs.uk, Flax Bourton BS48 1UL Dear Miss Voisin In response to your letter to the Trust under Regulation 28 | am writing to re-assured you that the process surrounding the management of children from the moment they enter the Emergency Department has been substantially revised and strengthened in a way which | very much hope will avoid a repeat of the circumstances surrounding the death of Chloe Flavell. For your further assurance | enclose a copy of a summary paper of actions taken around paediatrics and presented to the Board on 7" January. Within this paper you will see the new pathways along which paediatric patients can be managed. | would draw your particular attention to the role of the Clinical Navigator. This individual, stationed opposite the reception area in the Emergency Department, has the responsibility of scanning patients as they come into the Department and actively seeking out children who will then be fast tracked along whatever pathway seems most appropriate. The changes illustrated in the paper have all been enacted. However, if you require further detail or have other observations to make please do not hesitate to contact me. Best wishes. / Yours sincerely Medical = Weston Area Health Trust (oxen Nick Wood, Chief Executive Associate Director of Governance & Patient Experience ae OfO/ a Chairman: Peter Carr Chief Executive: Nick Wood
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