Prevention of Future Deaths reports · 2014
Regulation 28 report to prevent future deaths, reference 2014-0065, written 17 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 | 17 Feb 2014 |
|---|---|
| Reference | 2014-0065 |
| Deceased | Selina Broadhurst |
| Coroner | John Pollard |
| Coroner area | Manchester South |
| Category | Community health care and emergency services 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: Chief Executive Office, National Institute for Health and Care Excellence, 10, Spring gardens, London SW1A 2BU 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 21" February 2013 | commenced an investigation into the death of Selina Isabella Broadhurst dob 1* January 1927. The investigation concluded on the12" February 2014 and the conclusion was one of Accidental Death. The medical cause of death was 1a Bronchopneumornia 1b Intra-cerebral Haemorrhage and 2 Vascular dementia and Type two diabetes mellitus. 4 | CIRCUMSTANCES OF THE DEATH: On the 14" February 2013 she fell at the E.P.H. where she lived and suffered a blow to the head. She was admitted to hospital and, inter alia, she was not afforded a CT scan of her head until a second admission some hours later when she was shown to have a major bleed to the brain. This was despite the fact that she had an external injury to the front of her scalp. 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. The Emergency Department doctors indicated that they could not get a CT of the head because “the NICE Guidelines do not indicate as being appropriate where there are no obvious neurological signs”. | have noted in this inquest and indeed in a number of inquests previously that the doctors are following these guidelines and in fact many severe brain injury cases are being missed or there is a delay in diagnosis. Is it not now time that this guideline was re-examined and the advice amended, especially when dealing with the very frail elderly patient? 6 | ACTION SHOULD BE TAKEN In 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. YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 14" 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 —iiiiiniiai Chief Coroner and to the following Interested Persons namely (daughter of the deceased) and the Chief Executive of the Tameside Hospital NHS Foundation Trust. | 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. 47" January 2014 John Pollard, HM Senior Coroner
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