Prevention of Future Deaths reports · 2014
Regulation 28 report to prevent future deaths, reference 2014-0056, written 31 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 | 31 Jan 2014 |
|---|---|
| Reference | 2014-0056 |
| Deceased | William Kent |
| Coroner | Karen Henderson |
| Coroner area | Surrey |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| Organisation named | Ashford Hospital NHS 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 THIS REPORT IS BEING SENT TO: 1. Chief Executive, St Peters and Ashford hospitals Chertsey 2. Chief Executive, Guest Medical 3. MHRA 1 CORONER I am Karen HENDERSON, Assistant Coroner for the coroner area of Surrey 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 January 23rd 2014 I commenced an investigation into the death of William George KENT, years of age. The investigation concluded at the end of the inquest on 23rd December 2013. The medical cause of death given was: 1a. Ischaemic heart disease 1b. Coronary artery atheroma, calcific aortic stenosis and chlorine inhalation 1c. 2. Infective exacerbation of chronic obstructive pulmonary disease My narrative conclusion was: Whilst general frailty of health and ischaemic heart disease were likely to be co-factors it is clear that inhalation of chlorine was a significant contributing trigger which led to death 4 5 CIRCUMSTANCES OF THE DEATH Mr Kent was admitted into St Peter’s Hospital Chertsey on 20th December 2012 after a fall at home. He was transferred to Ashford Hospital on 25th December 2012 for rehabilitation and management of his social circumstances and further treatment of his leg ulcers. At or around 0800 on 30th December 2012 a reasonably substantial quantity of ‘Haz-Tab’ granules was sprinkled on a large amount of urine on the floor next to Mr Kent’s bed and left for approximately ten minutes. This caused sore eyes and coughing for the person dispensing the granules. Shortly thereafter Mr Kent was seen to become acutely short of breath and in obvious respiratory distress. He was maximally treated at Ashford Hospital but there was no improvement in his condition and he was transferred to St Peter’s Hospital, Chertsey for further treatment. Unfortunately this was no successful and Mr Kent died at 20.16 on 30th January 2012. CORONER’S CONCERNS During the course of the inquest the evidence revealed matters giving rise for concern. In my opinion there is a risk that future death 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. Lack of awareness of the potentially harmful side-effects of Haz-Tab granules for urine spillages 2. Limited time given over to the teaching of the side-effects of cleaning products such as Haz-Tab granules at the induction of new staff and at yearly mandatory infection control updates RT3857 3. Lack of clarity on how Haz-Tab granules should be used in clinical spillages 4. An under-emphasis of the potential hazardous consequences from the release of noxious gases when Haz-Tab granules are in contact with urine (with or without contamination of blood) 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you and your organisation: St Peters and Ashford Hospital NHS Trust, Guest Medical, and MHRA have the power to take such action. 7 YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 22nd April 2014. I, the coroner, may extend this 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: (Guest Medical) who may find it useful or of (daughter) and 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: 31-1-2014 SIGNED: Dr K Henderson RT3857
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