Prevention of Future Deaths reports · 2014
Regulation 28 report to prevent future deaths, reference 2014-0250, written 2 Jun 2014. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 2 Jun 2014 |
|---|---|
| Reference | 2014-0250 |
| Deceased | Essa Shah |
| Coroner | Tom Osborne |
| Coroner area | Bedfordshire & Luton |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
REGULATION 28: REPORT TO PREVENT FUTURE DEATHS (1)
NOTE: This form is to be used after an inquest.
THIS REPORT is being sent to:
Ms Pauline PHILIP
Chief Executive
L & D University Hospital
Lewsey Road
Luton
LU4 4DZ
1
CORONER
I am Mr Tom OSBORNE, Senior Coroner for the Coroner Area of
Bedfordshire and Luton.
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.
http://www.legislation.gov.uk/ukpga/2009/25/schedule/5
3
INVESTIGATION and INQUEST
On the 30th of October 2013 I commenced an Investigation into the death
of Essa SHAH aged 8 weeks. The Investigation concluded at the end of
the Inquest on 21st May 2014 at which I recorded an ‘Open Conclusion’,
the medical cause of death being :
I (a) Unascertained (Sudden Unexpected Death in Infancy)
4
CIRCUMSTANCES OF THE DEATH
Essa Shah was eight weeks old when he went to sleep in the same bed as
his mother on 17th October 2013 following a feed. Mother and father were
smokers. He was later found unresponsive.
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:
1. That the literature, setting out the dangers of co-sleeping which the
hospital hand to new mothers being discharged, is only available in
the English Language.
6
ACTION SHOULD BE TAKEN
In my opinion action should be taken to prevent future deaths and I
believe you, as the Chief Executive of the Luton & Dunstable University
Hospital, 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 28th July 2014; I, 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.
8
COPIES and PUBLICATION
I have sent a copy of my Report to
the Chief Coroner
and to the following Interested Person(s):
The Family
Secretary of State for Health
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
Dated this 2nd day of June 2014
……………………………………
Tom OSBORNE
Senior Coroner
Bedfordshire & Luton
1 response published against this report on judiciary.uk. A response is a body's written reply to the coroner's concerns; publication is at the discretion of the Chief Coroner's office, so an absent response does not mean nobody replied.
Our ref: PMP/ams 28 July 2014 Coroner's Officer ail HM Coroner's Office e-mail: The Court House Woburn Street Ampthill Bedfordshire MK45 2HX Dear Mr Smith Inquest touching the death of Essa SHAH Inquest held on 21st May 2014 at Coroner’s Court, Ampthill Thank you for your Regulation 28 Report, dated 2™ June 2014, in response to the death of Essa Shah. The Trust has considered the following matter of concern: 1) That the literature, setting out the dangers of co-sleeping which the hospital hand to new mothers being discharged, is only available in the English language. At present, women are given two leaflets that advise of the dangers of co-sleeping: upon transfer from the Delivery Suite to the ward they are given a “Caring for your Baby at Night” leaflet published by UNICEF as part of their Feeding Pack; upon discharge from the ward to home, they are given the “Reduce the Risk of Cot Death” created by the Department of Heath but now printed by the Trust as the Department of Health (DoH) have ceased to produce it. In addition to leaflets, the Trust has produced a video, in three languages (English, Polish and Urdu) which is available on the Trust's website and on DVD. The video includes a section about discharge and caring for your baby at home. The video was produced in response to a consultation with local communities who told us that whilst it was common for women to speak their mother tongue, they were often unable to read it. The Community Midwives have prompt sheets to ensure that safe sleeping practices are discussed with women face to face and they will shortly be equipped with iPads to facilitate communication with anyone who is uncertain as to what they are being told verbally. The Trust is unable to facilitate the translation of the Department of Health leaflet, which is only available in English, due to the considerable practical and financial implications. As the Luton and Dunstable University Hospital NHS) ABS foungot.an Tast DoH no longer produces this leaflet, we are not able to approach them for their assistance. However, UNICEF produce a leaflet called “Sharing a bed with your baby” which is available in 11 languages, three of which are relevant to the population we serve. The Trust will now ensure Feeding Packs are created containing this leaflet in Bengali, Punjabi and Urdu; the leaflet is not available in Polish so we will continue to use the video we have produced and verbal communication. We hope this addresses your concerns. Yours sincerely Pauline Philip Chief Executive Officer
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