Prevention of Future Deaths reports · 2014
Regulation 28 report to prevent future deaths, reference 2014-0032, written 23 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 | 23 Jan 2014 |
|---|---|
| Reference | 2014-0032 |
| Deceased | Desrae Tucker |
| Coroner | Wendy James |
| Coroner area | Gwent |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| 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:
Dr Andrew Goodall, Chief Executive, Aneurin Bevan Health Board,
Headquarters, Block A, Mamhiiad House, Mamhilad Park Estate,
Pontypool! NP4 0YP
1 | CORONER
lam Wendy Ann James, assistant coroner, for the coroner area of Gwent
2 | CORONER’S LEGAL POWERS
1 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 28-03-13 | commenced an investigation into the death of DESRAE REGINA
TUCKER (d.0.b. 18/06/44). The investigation concluded at the end of the inquest on the
04-12-13. The conclusion of the inquest was that Desrae Regina Tucker died as a result
of a recognised complication following a necessary surgical procedure, the medical
cause of death being:-
1 (a) Pulmonary embolism
{b) Deep vein thrombosis
2 Recent Cholecystectomy (operated)
4 | CIRCUMSTANCES OF THE DEATH
On 12-03-13 Mrs. Tucker was admitted as an emergency to the Royal Gwent Hospital
with abdominal pain. She subsequently underwent surgery for removal of her gall
bladder on 20-03-13. She was discharged home on 24-03-13 and died at home on
26-03-13.
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. —
(1) The lack of recording in the patient's notes as to whether the patient was wearing
the anti-embolic stockings prescribed.
(2) No consideration given as to whether the patient should be discharged home with
anti-embolic stockings.
(3) No anti-coagulant medication prescribed to the patient upon discharge.
ACTION SHOULD BE TAKEN
In my opinion action should be taken to prevent future deaths and | believe you and 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 19-03-14. |, 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
Ihave fF my report to the Chief Coroner and to the following Interested
Persons]
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
23-01-14 WhAdamer .
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