Prevention of Future Deaths reports · 2014

Sidney Harvey

Regulation 28 report to prevent future deaths, reference 2014-0075, written 26 Feb 2014. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.

Date of report26 Feb 2014
Reference2014-0075
DeceasedSidney Harvey
CoronerSiobhan Kelly
Coroner areaSouth Lincolnshire
CategoryOther related deaths
Sourcejudiciary.uk record · original PDF
Responses publishednone published

The report

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.

A R W Forrest tw, ercp, FRcPath
GMC Number: 1333523

Her Majesty's Senior Coroner for South Lincolnshire

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:

1. Fs Strategic Director of Housing and Neighbourhoods, South

Kesteven District Council

CORONER

| am Siobhan Kelly, Assistant Coroner for the Coroner's area of South Lincolnshire.

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.

INVESTIGATION and INQUEST

On 5" December 2013, ARW Forrest commenced an investigation into the death of
Sidney Harvey, age 90. The investigation concluded by Siobhan Kelly at the end of the
inquest on 20" February 2014. The conclusion of the inquest was Accident Death due

to haemorrhage due to incised wound of left forearm.

CIRCUMSTANCES OF THE DEATH

Sidney Harvey was a 90 year old gentleman who lived in a council property. The house
contained at least 2 doors which were entirely made of glass except for the frame. The
glass was not safety glass and therefore when it broke, it formed some large shards and
Mr Harvey sustained a severe cut 8cm x 5cm and 4cm in depth which cut through

muscles, tendons and vasculature down to the bone.

A RW Forrest tum, rrcp, FRcPath
GMC Number: 1333523

Her Majesty's Senior Coroner for South Lincolnshire

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 presence of non-safety glass doors in properties rented where occupants
are likely to include the elderly and children or other who may be unstable
physically

2. Whether any system exists for replacing or making safe such glass doors.

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 30" 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
| 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

A R W Forrest tum, ercp, rrcpath
GMC Number: 1333523
Her Majesty's Senior Coroner for South Lincolnshire

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: 2o/2/ 14

S Kelly os 3ooseet et Net tr

HM Assista er for South Lincolnshire

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