Prevention of Future Deaths reports · 2014
Regulation 28 report to prevent future deaths, reference 2014-0327, written 16 Jul 2014. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 16 Jul 2014 |
|---|---|
| Reference | 2014-0327 |
| Deceased | Silvia Taylor |
| Coroner | Martin Fleming |
| Coroner area | Surrey |
| Category | Community health care and emergency services 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.
IN THE SURREY CORONER’S COURT IN THE MATTER OF: __________________________________________________________ The Inquest Touching the Death of Silvia Eileen Taylor A Regulation 28 Report – Action to Prevent Future Deaths __________________________________________________________ THIS REPORT IS BEING SENT TO: Chief Executive – Harmoni South East Home Support Team Leader ‐ Woking Borough Council Forestcare – Bracknell Forest Council 1 CORONER Martin Fleming Assistant Coroner for Surrey 2 CORONER’S LEGAL POWERS I make this report under the Coroners and Justice Act 2009 paragraph 7, schedule 5 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. 3 INVESTIGATION and INQUEST On 14/2/13 I opened the inquest into the death of Silvia Eileen Taylor, who at the date of her death was 81 years old. The inquest was resumed and concluded on 14/7/14. I found that the cause of death to be: 1a – Ischaemic Heart Disease I concluded with a narrative conclusion as follows: On 8/2/13, Silvia Eileen Taylor was found to have died at her home address of ischaemic heart disease. She had earlier activated her emergency pendant for the attendance of the doctor, although several subsequent attempts by the doctors to contact her by telephone were unsuccessful. It is found more likely than not, that earlier medical intervention would not have affected the outcome. RT4159 1 4 CIRCUMSTANCES OF THE DEATH On 7/2/13 at 10.06pm Silvia Eileen Taylor activated her care alarm at her home address resulting in an immediate response from the Emergency Response Officer. Mrs Taylor complained of stomach pains and requested a Thamesdoc. The family was contacted soon after and informed that a GP was to attend within 25 minutes. Subsequently Thamesdoc doctors made several unsuccessful attempts to contact Mrs Taylor by phone at her home address. Upon the arrival of the Thamesdoc doctor at her home address at 2.30am her lack of response prompted him to contact the family to request a key to the premises. The family found upon arrival that they could not enter via the front door with the key since it had been bolted internally. The GP left to attend an emergency call after discussing matters with the family. Subsequently the police were called and entry was forced at 4am when Mrs Taylor was found to have died on her bed. 5 CORONER’S CONCERNS During the inquest the following concerns arose: ‐ Although initial reports from Mrs Taylor gave no concern for the need for urgent medical attention, unsuccessful attempts to contact her were not acted upon for several hours. The difficulties in establishing telephone contact with Mrs Taylor, were not conveyed to the family. I would ask that you consider giving further consideration to the no speech call procedures in relation to after hours support. 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe that Harmoni, Woking Borough Council and Forestcare has the power to take such action. 7 YOUR RESPONSE You are under a duty to respond to this report within 56 days of its date; I may extend that period on request. Your response must contain details of action taken or proposed to be taken, setting out the timetable for such action. Otherwise you must explain why no action is proposed. RT4159 2 8 COPIES The Chief Coroner 9 Signed: Martin Fleming DATED this 16‐Jul‐2014 RT4159 3
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.
Care & Care UK Health Care Division PRIVATE AND CONFIDENTIAL HM Coroner for Surrey HM Coroner's Court Hawker House Station Approach ; . Woking 5-6 Napier Court Surrey Reading GU22 7AP Berkshire RG1 8BW 25"" September, 2014 www.careuk.com Dear Sirs, Mrs Silvia Taylor (deceased) — Regulation 28 report: action to prevent future deaths We are writing in response to HM Coroner's Regulation 28 report following the Inquest into the sad death of Mrs. Silvia Taylor on 7'" February, 2013 (copy attached for reference). Paragraph 5 of the report states: “During the inquest the following concerns arose: e Although initial reports from Mrs Taylor gave no concern for the need for urgent medical attention, unsuccessful attempts to contact her were not acted upon for several hours. e The difficulties in establishing telephone contact with Mrs Taylor were not conveyed to the family. ! would ask that you consider giving further consideration to the no speech call procedures in relation to after hours support.” Following receipt of the report we have reviewed and updated the policy as to how our current services should proceed if we make a telephone call to a patient and there is no reply (policy attached for reference). The policy has addressed two points where a patient may need contact from Care UK’s out of hours GP service: 4. Scenario 1 is where a patient’s phone number has been received by the out of hours service because the patient needs further assessment over the telephone by a clinician. 2. Scenario 2 is where the patient's phone number has been received by the out of hours GP service from the NHS 111 service because the NHS pathways algorithm has determined that the patient needs an appointment to be seen face to face. Care UK Clinical Services Limited — Primary Care Division. Registered in England No 3462881 Registered Office: Connaught House, 850 The Crescent, Colchester Business Park, Colchester, Essex CO4 9QB This policy change has happened in consultation with Care UK’s senior doctors: National Medical Directors for Practices and for Health in Justice, Medical Director for Primary Care and the Regional Medical Directors within Primary Care. This policy was ratified at the Clinical Quality and Governance Committee Meeting for Healthcare on 22" September, 2014. Yours sincerely, Medical Director for Primary Care Care UK Care UK Clinical Services Limi Registered Office: Connaught Hot ex CO4 SQB
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