Prevention of Future Deaths reports · 2014
Regulation 28 report to prevent future deaths, reference 2014-0080, 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 report | 26 Feb 2014 |
|---|---|
| Reference | 2014-0080 |
| Deceased | Bertram Hamilton |
| Coroner | Robin Balmain |
| Coroner area | Black Country |
| 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.
Smethwick Council House
High Street
er Smethwick
Robin J. Balmain }) West Hlcted eH
H.M. SENIOR CORONER ws
G&S
Tel: 0845 352 7483
BLACK COUNTRY Fax: 0121 569 5384
(SANDWELL ¢ DUDLEY ¢ WALSALL ¢ WOLVERHAMPTON mail:
Metropolitan Borough Councils) fe
Date: 26 February 2014 Our Ref: RJB Your Ref:
REGULATION 28 REPORT TO PREVENT FUTURE DEATHS
THIS REPORT IS BEING SENT TO:
Nursing and Midwifery Council
First Floor,
1 Kemble Street
London
WC2B 4AN
1. CORONER
I Robin John Balmain am the Senior Coroner for the Black Country Coroners
Jurisdiction
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.
8 INVESTIGATION AND INQUEST
On 234 March 2011 I commenced an investigation into the death of Bertram
Theophilus HAMILTON of Mansby House, Ryland View Nursing Home, Arnhem
Way, Tipton, West Midlands. The investigation concluded at the end of the inquest
on 21st February 2014. The conclusion of the inquest was that death was due to
Natural Causes.
4. CIRCUMSTANCES OF THE DEATH
Mr. Hamilton had been a long term resident in a care home. On the morning of his
death, his blood sugar was checked because he was diabetic and_was found to be 1.6
but despite this an injection of insulin was given by a nurse fr
Although Mr. Hamilton died shortly afterwards, the expert evidence was to the effect
that the insulin probably did little harm in the context of Mr. Hamilton’s then existing
condition.
5. CORONERS CONCERNS
I am concerned that the nurse in question appeared not to know that insulin should
not be given to a person whose blood sugars were so low. In addition, I was
This Office is open Monday to Thursday 8am to 4pm. Friday 8am to 3pm
SENIOR CORONER
26 February 2014 Continuation
| ST SSS
concerned that the nurse was not frank and open in giving evidence to me and
claimed that she had given Mr. Hamilton a sugary solution, that she had re-checked
his blood sugars and gave the insulin only after the blood sugar level was high.
None of the contemporaneous documentation, including documentation completed
by the nurse herself, supported such a contention.
The MATTERS OF CONCERN are as stated above and relate to the question
of whether the nurse is a fit and proper person to act as such.
i ACTION SHOULD BE TAKEN
In my opinion action should be taken to prevent future deaths and I believe you 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 the
report, namely by 25th April 2014,
COPIES and PUBLICATIONS
I have sent a copy of my report to the Chief Coroner and to the following interested
Persons :
a) The Nurse}
b) The BUPA Care Home,
c) Ryland View Nursing Home, Arnhem Way, Tipton, West Midlands.
d) The Care Quality Commission
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.
R.J. Balmain
Senior Coroner
BAP
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