Prevention of Future Deaths reports · 2014
Regulation 28 report to prevent future deaths, reference 2014-0026, written 21 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 | 21 Jan 2014 |
|---|---|
| Reference | 2014-0026 |
| Deceased | John Malone |
| Coroner | John Pollard |
| Coroner area | Manchester South |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| Organisation named | Tameside Hospital NHS Foundation 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
REGULATION 28 REPORT TO PREVENT FUTURE DEATHS
THIS REPORT IS BEING SENT TO:
The Chief Executive Officer, Tameside Hospital NHS Foundation Trust
1 | CORONER
| am John Pollard, senior coroner, for the coroner area of South Manchester
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 29" October 2013 | commenced an investigation into the death of John Joseph
Malone dob 16" January 1932. The investigation concluded at the end of the inquest on
8” January 2014. The conclusion of the inquest was that Mr Malone suffered two falls at
his home address, the first several weeks before his death and the second on the 24"
October 2013 which led to his sustaining a subdural Haematoma and | concluded that
he had died an accidental death.
4 | CIRCUMSTANCES OF THE DEATH
As paragraph 3 above
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. —
| took evidence from the two GP’s caring for the deceased and they showed to me, inter
alia, a discharge letter from your hospital dated 21° October 2013 a copy of which |
append hereto. You will note that this document is woefully short on detail and has
significant omissions of vital information for the GP’s. On page one of the report there
are no details given as to Admission date, admission ward, admission method,
admission source, discharge destination or discharge date. The patient sustained a fall
within 3 days of his discharge and this led to or exacerbated his subdural haemorrhage.
6 | ACTION SHOULD BE TAKEN
{n my opinion action should be taken to prevent future deaths and | believe you have
the power to take such action. It is essential that full information is passed promptly to
the GP practice of a patient being discharged.
7 | YOUR RESPONSE
You are under a duty to respond to this report within 56 days of the date of this report,
namely by 4” 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 to the following Interested
Persons namely {NN daughter of the deceased. | have also sent it to the
CQC and CCG for Tameside who may find it useful or of interest.
! 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.
14" January 2014 John Pollard, HM Senior Coroner
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