Prevention of Future Deaths reports · 2014
Regulation 28 report to prevent future deaths, reference 2014-0090, written 24 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 | 24 Feb 2014 |
|---|---|
| Reference | 2014-0090 |
| Deceased | James Sutton |
| Coroner | Andrew Walker |
| Coroner area | London (North) |
| Category | Hospital Death (Clinical Procedures and medical management) 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.
‘Her Majesty's Coroner for the - 29 Wood Street, Northern District of Greater Loridon Barnet ENS 4BE (Harrow, Brent, Barnet, Haringey and Enfield) Telephone 0208 447 7680 Fax 0208 447 7689 REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: 1. Department of Health Department of Health Richmond House 79 Whitehall London SW1A 2NS CORONER | am Andrew Walker, senior coroner, for the coroner area of Northern District of Greater London 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 the 30" July 2013 | opened an inquest touching the death of Graham James Sutton, aged 65 years old. The investigation concluded at the end of the inquest on the 17" February 2014. The conclusion of the inquest was “Accident”, the medical case of death was ;1a Subdural Haemorrhage (operated 11.7.2013) , 1b Head Injury. CIRCUMSTANCES OF THE DEATH On the 10" July 2013 Graham James Sutton fell 5 feet from a ladder and struck his head on concrete whilst cutting a hedge. Mr Sutton was able to get up and took himself to bed. Mr Sutton was then taken by ambulance to hospital before being transferred to a Trauma Centre where despite treatment he died. 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 fact that Mr Sutton had fallen as little as 5 feet, that he was over 50 years old and that he was taking anti-clotting medications, (Clopidogrel), were not linked automatically by the London Ambulance Service to result in a response within 8 minutes. ACTION SHOULD BE TAKEN North London Coroners Court, Her Majesty’s Coroner for the ° yale’ Northern District of Greater Lorton (Harrow, Brent, Barnet, Haringey and Enfield) 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 Monday 21 March 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 London Ambulance Service and members of the family. 1am 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 rdlease or the publication of your response by the Chief Coroner. 24" Febrifary 2014
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