Prevention of Future Deaths reports · 2014
Regulation 28 report to prevent future deaths, reference 2014-0063, written 13 Feb 2014. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 13 Feb 2014 |
|---|---|
| Reference | 2014-0063 |
| Deceased | John Davies |
| Coroner | Dr Fiona Wilcox |
| Coroner area | London Inner (West) |
| Category | Other 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 REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: 1. Mr Niall Dickson, Chief Executive, GMC, 3, Hardman street, Manchester. M3 3AW. 2. Mr Simon Kayel, Chief Executive, Medical Protection Society, 33, Cavendish Square, London. W1G OPS. President, Royal College of Physicians, 11 St Andrews Place Regent’s Park London NW1 4LE 1 | CORONER | am Dr Fiona Wilcox, Senior Coroner, for the coroner area of Inner West London 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 14" June 2013 | commenced an investigation into the death of Professor John Elfed Davies, aged 71yrs. The investigation concluded at the end of the inquest on 31° October 2013. The conclusions of the inquest were as follows: Injury or disease causing death: I(a) Incised wounds to neck and multiple stab wounds to the chest. How, when and where Professor Davies came by his death: On Monday 10" June 2013, a 71 year old male was found deceased lying on the floor of his hotel room. He had self inflicted incised wounds to his neck and multiple stab wounds to his chest. A note was found in the room confirmed to be in his handwriting. His death was deemed non suspicious by police. He was concerned about his health, finances and a complaint that had been made about his practice to the GMC. Conclusion of the coroner as to the death: He took his own life. CIRCUMSTANCES OF THE DEATH A note found at the scene clearly indicated that the proceedings against him by the GMC were very much playing on his mind at the time he took his own life. 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. — This is the second death of a doctor that has come before me over the last 2 years where a GMC investigation into the doctor’s practice has been found to play a part. | am concerned that clinicians who are subject to such investigative processes are suffering adverse psychological effects which may be unrecognised and unsupported. Consideration should be given to the language and tone of written communications, the provision of information about relevant support agencies, and the assessment and identification of suicidal or other self harming behaviour by the relevant body and the facilitation of appropriate on-ward referral. It is for each organisation to which this report is addressed to consider any appropriate and specific actions for them to take. ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and | believe you [AND/OR 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 10" April 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: | have also sent it to: Raglan Surgery, Chepstow Road, Raglan, Usk, Monmouthshire. NP15 2EN. Consultant Surgeon 54 Hanover Gate Mansions Park Road London NW1 4SN 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. —| 13" February 2014 Dr Fiona Wilcox HM Senior Coroner Inner West London.
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