Prevention of Future Deaths reports · 2014
Regulation 28 report to prevent future deaths, reference 2014-0022, written 16 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 | 16 Jan 2014 |
|---|---|
| Reference | 2014-0022 |
| Deceased | Jackie Scott |
| Coroner | Tony Brown |
| Coroner area | North Northumberland |
| Category | Product related deaths |
| 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.
Tony Brown LLM
H M Senior Coroner
North Northumberland
Teleph
17 Church Street
Berwick-upon-Tweed
TD15 1EE
Tel : 01289 304318
Fax : 01289 303591
REGULATION 28: REPORT TO PREVENT FUTURE DEATHS
REGULATION 28 REPORT TO PREVENT FUTURE DEATHS
THIS REPORT IS BEING SENT TO:
1. The Owner
INDIAN BRASSERIE
40-42 Main Street
Seahouses
NE68 7RQ
1
CORONER
I am Tony Brown, senior coroner, for the coroner area of North Northumberland
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 25th June 2013 I commenced an investigation into the death of Jackie Scott, age 35
years. The investigation concluded at the end of the inquest on 19th November 2013.
The conclusion of the inquest was that Jackie Scott died from natural causes, the
medical cause of death being:-
1a Acute Anaphylaxis
4
CIRCUMSTANCES OF THE DEATH
Jackie Scott lived in Aberdeen but was volunteering at Bamburgh, Northumberland on
an archaeological dig. He was staying with colleagues at a camp site in Seahouses. On
20th June 2013 Mr Scott returned to the camp site at around 18.13 hours after collecting
a curry from a local Indian restaurant (The Indian Brasserie). On eating the food with
colleagues Mr Scott became ill and lost consciousness. A colleague performed CPR
until an ambulance arrived. Resuscitation attempts were continued and Jackie Scott
was taken to Wansbeck General Hospital where death was confirmed at 20.27 hours
due to a suspected allergic reaction.
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 was informed at the Inquest by Jackie Scott’s parents that he had been able to eat
take-away curries in the past without any problems but it is believed that his allergic
reaction was likely to have arisen from consuming food containing peanuts or peanut oil.
It seems that Jackie Scott would have been unaware that the food he purchased (Tikka
Massala) may have contained peanut oil or peanuts. Given the timing of his sudden
allergic reaction which occurred as soon as he ate the meal, which sadly lead to his
death from anaphylactic shock, it is almost certain that this was a result of the meal he
consumed without knowing that it contained peanuts or peanut oil.
6
ACTION SHOULD BE TAKEN
In my opinion action should be taken to prevent future deaths and I believe you and/or
your organisation have the power to take such action. It is known that a number of food
manufacturers, suppliers and restaurants display warnings on their products, menus or
premises, alerting customers who might be allergy sufferers to the fact that products
sold may contain peanuts or peanut oil. You are asked to consider taking similar action
to warn customers in the hope that a similar death in the future might be prevented.
7
YOUR RESPONSE
You are under a duty to respond to this report within 56 days of the date of this report,
namely by 17th March 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,
I have also sent it to the Acting Director of Public Health (
Northumberland County Council who may find it useful or of interest.
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 16th January 2014
TONY BROWN
HM Senior Coroner for North Northumberland
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