Prevention of Future Deaths reports · 2014
Regulation 28 report to prevent future deaths, reference 2014-0099, written 5 Mar 2014. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 5 Mar 2014 |
|---|---|
| Reference | 2014-0099 |
| Deceased | Barry Dillion |
| Coroner | Michael Singleton |
| Coroner area | Blackburn, Hyndburn & Ribble Valley |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| Organisation named | East Lancashire Healthcare NHS Trust |
| Source | judiciary.uk record · original PDF |
| Responses published | none published |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
REGULATION 28: REPORT TO PREVENT FUTURE DEATHS (1)
REGULATION 28 REPORT TO PREVENT FUTURE DEATHS
THIS REPORT IS BEING SENT TO:
The Chief Executive Officer
East Lancashire Healthcare NHS Trust
Trust Headquarters
The Royal Blackburn Hospital
Haslingden Road
Blackburn BB2 3HH
1
CORONER
I am Michael Singleton, Senior Coroner for the Coroner area of Blackburn, Hyndburn
& Ribble Valley.
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.
3
INVESTIGATION and INQUEST
On 14 November 2013, I commenced an investigation into the death of Barry
Joseph Dillon, aged 68. The investigation concluded at the end of the Inquest on
the 4th day of March 2014. The conclusion of the Inquest was that Barry Joseph
Dillon had died as a consequence of aspiration pneumonia due to dementia; the
conclusion being that of natural causes.
4
CIRCUMSTANCES OF THE DEATH
Barry Dillon had been detained on Ward 19 at Burnley General Hospital, pursuant to
Section 6 of the Mental Health Act 1983, and was transferred to the Royal Blackburn
Hospital following seizures. Whilst at the Royal Blackburn Hospital he had suffered
a number of aspiration pneumonias, finally succumbing on 13 November 2013.
5
CORONER’S CONCERNS
During the course of the Inquest the evidence revealed matters giving arise to
concern. In my opinion there is a risk that further deaths will occur unless action is
taken. In the circumstances it is my duty to report to you the MATTER OF
CONCERN is as follows: -
I received evidence from
, a Specialist Speech and Language Therapist,
who stated “There are currently insufficient resources to provide a comprehensive
SLT service at the Royal Blackburn Hospital. The Royal College of Speech and
1
Language Therapists’ guidelines recommend a two working day response time to
referrals for a swallow assessment. This is not achieved by the SLT service at the
Royal Blackburn Hospital and there is a risk assessment in place which is currently
on the East Lancashire Hospitals Trust Corporate Risk Register with an
accompanying business case identifying the resources required to address the
shortfall in provision”.
Although Mr Dillon had been referred to the Speech and Language Therapy Service
on 17 October 2013, no action was taken until 1 November 2013. I believe that
whilst there remain insufficient resources to provide the service at the Royal
Blackburn Hospital patients will continue to be at risk of the development of
aspiration pneumonia which may prove to be fatal.
6
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.
7
YOUR RESPONSE
You are under a duty to respond to this report within 56 days of the date of this
report, namely by 2 May 2014. I, the Coroner, may extend this 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.
8
COPIES and PUBLICATION
I have sent a copy of my report to the Chief Coroner and to the following interested
person, namely:
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.
9
5 March 2014 Signed by: …………………………………………….
H M Senior Coroner for Blackburn,
Hyndburn & Ribble Valley
2
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