Prevention of Future Deaths reports · 2014
Regulation 28 report to prevent future deaths, reference 2014-0283, written 25 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 | 25 Jun 2014 |
|---|---|
| Reference | 2014-0283 |
| Deceased | Wilfred Aspinwall |
| Coroner | Andre Rebello |
| Coroner area | Liverpool |
| Category | State Custody related deaths |
| 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)
NOTE: This form is to be used after an inquest.
REGULATION 28 REPORT TO PREVENT FUTURE DEATHS
THIS REPORT IS BEING SENT TO:
Prison and Probation Ombudsman
2 Monck Street
London
SW1P 2BQ
1
CORONER
I am André Rebello, Senior Coroner, for the area of Liverpool
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 the 30th April 2013 I commenced an investigation into the death of Wilfred Roy
ASPINWALL by opening an inquest under the Coroners Act 1988
, Aged 82. The investigation concluded at the end of the inquest on 24th June 2014. The
conclusion of the inquest was
Ia Congestive Heart Failure
Ib Hypertensive Heart Disease
II Recurrent and Metastatic Lung Carcinoma
Wilfred Roy Aspinwall died of Natural Causes
4
CIRCUMSTANCES OF THE DEATH
Wilfred Aspinwall was a prisoner at HMP Liverpool. He was a frail gentleman with
several co-morbidities. Whilst in Prison was residing on the health care ward. He had
sustained previous falls at prison and sustained a further fall on 7th/8th March 2013,
fracturing his hip and was then transferred to University Hospital Aintree. Whilst in UHA,
he has sustained further falls on Ward 35. He suffered a gradual deterioration of health
and on Sunday 21st April 2013, Wilfred’s breathing became laboured at 0910hours and
he sadly died. Medical history included Lung cancer, with part of lung being removed in
1995, renal failure and worsening dementia. There was considerable confusion
concerning the cause of death after both a consultant histopathologist and a consultant
neuropathologist attributed fatal events to cerebral pathology caused by falls. The Court
instructed a consultant neurosurgeon who met with the pathologists reviewed the clinical
presentation including scans, where after all three doctors agreed that the death was
due to natural causes.
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
1
circumstances it is my statutory duty to report to you.
The MATTERS OF CONCERN are as follows. –
At the inquest hearing it was clear that the PPO report and Clinical Review had not been
sent to nor shared with the Healthcare provider at HMP Liverpool. It might be considered
good practice for future reports, in all prison fatalities should to be sent to either the head
of healthcare and/or the commissioning NHS Trust to ensure that recommendations
have an optimal effect.
6
ACTION SHOULD BE TAKEN
In my opinion action should be taken to prevent future deaths and I believe you
[AND/OR your organisation] 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 20th August 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.
COPIES and PUBLICATION
I have sent a copy of my report to the Chief Coroner and to the following Interested
Persons
The Family of Mr Aspinwall
NOMS
HMP Liverpool
Liverpool Community NHS Trust
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.
8
9
André Rebello
Senior Coroner for the
City of Liverpool
Dated: 25th June 2014
2
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