Charles Pierson

REGULATION 28: REPORT TO PREVENT FUTURE DEATHS

REGULATION 28 REPORT TO PREVENT FUTURE DEATHS |

1, West Hertfordshire Hospitals NHS Trust

THIS REPORT IS BEING SENT TO:
|
i
|

1 CORONER

| am Richard Alexander Hulett Senior Coroner, for the coroner area of Buckinghamshire

2 | 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.

3 | INVESTIGATION and INQUEST

On 25" June 2013 | commenced an investigation into the death of Molly Rae Keen a
new born baby. The investigation concluded at the end of the inquest on 10” July
2014.The conclusion of the inquest was of natural causes together with a (J

4 | CIRCUMSTANCES OF THE DEATH
At 11.25 hours on 10" June 2013 Molly was delivered by caesarean section. She was
in a very poor condition. Resuscitation was stopped at 11.54.

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. —

4a) Buckinghamshire Healthcare NHS Trust (Bucks) employ a customised growth chart
as part of their ante natal care. Where ante natal care is provided in West Hertfordshire
Hospitals NHS Trust (West Herts) but the birth is intended to happen at Stoke
Mandeville Hospital then Bucks supply a growth chart to be kept in the mothers file and
utilised.

1b) West Herts do not use customised growth charts for their own deliveries.

1c) An expert witness in midwifery opined that where a chart is supplied, it should be
used.

1d) Discussions between Bucks and West Herts to improve this aspect of joint care are
currently in abeyance. There is a continuing absence of clarity as to how such joint care
should be delivered.

2) Midwives within West Herts estimate fetal growth by measuring fundal height.
However:-

a) In the immediate case, measurements were variously part recorded on the
growth chart, or written on the file, or not recorded at all. As a consequence, an overall
assessment of fetal growth is obscured.

b) The evidence disclosed that although there was (nevertheless), clear indication

that the growth of the baby was below normal expectations, no attempt was made to
refer the case for further opinion, and a possible scan.

3) Further information given during the inquest did not reassure me that all necessary
steps have been taken to remedy the issues outlined in 1 and 2 above.

ACTION SHOULD BE TAKEN

In my opinion action should be taken to prevent future deaths and | believe you AND/OR
your organisation has 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 47° September 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
Persons: Buckinghamshire Healthcare NHS Trust, and to the
Local Safeguarding Board

lam 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.

DATE: 22 July 2014 SIGNED BY CORONER: EE

A R W Forrest iw, rcp, Frcpath
GMC Number: 1333523

Her Majesty's Senior Coroner for South Lincolnshire
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:
1. Ms Samantha Peters, Chief Executive and Registrar, General Optical

Council, 41 Harley Street, Loondon, W1G 8DJ j
CORONER :

1

| am ARW Forrest, Senior Coroner for the Coroner's area of South Lincolnshire.

aed

2 | 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.

et
3 | INVESTIGATION and INQUEST

On 15" January 2014 | commenced an investigation into the death of Charles Albert
William Pierson, age 84 years. The investigation concluded at the end of the inquest on
6™ August 2014. The conclusion of the inquest was ACCIDENT.

4 | CIRCUMSTANCES OF THE DEATH

On 24" December 2013 at about 11.30am Mr Pierson and his wife arrived at the car
park at Tesco's store at Northgate, Sleaford. ae es: the vehicle to
collect a trolley. As Mr Pierson reversed into a disabled driving space an incident
occurred in which he collided with a bollard and knocked over He
then accelerated forward and collided with a kerb, then a lamp post. His seat belt
was fitted with a clip that inhibited its proper operation. This meant that his seat
belt did not prevent him from being thrown forward and sustaining the fractured
sternum that led to his death.

Unit 1, Gilbert Drive, Endeavour Park, Boston PE21 7TQ
Tel: 01522 553374 Fax: 01522 516717
Email: HMCoroner_Southlincolnshire@lincolnshire.gov.uk

A R W Forrest uum, ercp, FrcPath
GMC Number: 1333523
Her Majesty's Senior Coroner for South Lincolnshire

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. —

A practitioner registered with the General Optical Council gave a statement to the effect
that the deceased, when subject to an eye examination was able to meet the vision
standard set for drivers by the DVLA. A review of his documented findings by DVLA
staff indicated that was not the case. The DVLA opinion is that the deceased should
have been informed by his optician to inform DVLA of the findings. This was not done
and as a result the deceased continued to drive without a review of his vision defects by
the DVLA. | should tell you that there is no evidence that his vision defects contributed

to the collision that led to his death.

Lal

COPIES and PUBLICATION

ACTION SHOULD BE TAKEN
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 09" October 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.

| have sent a copy of my report to the Chief Coroner and to the following Interested

Persons:

EE 02005

2. Inspector Heads

Unit 1, Gilbert Drive, Endeavour Park, Boston PE21 7TQ
Tel: 01522 553374 Fax: 01522 516717
Email: HMCoroner_Southlincolnshire@lincolnshire.gov.uk

AR W Forrest uw, rrcp, FRcPath
GMC Number: 1333523

Her Majesty's Senior Coroner for South Lincolnshire

| 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.

> | 6" August 2014

H M Senior Coroner for South Lincolnshire

Unit 1, Gilbert Drive, Endeavour Park, Boston PE21 7TQ
Tel: 01522 553374 Fax: 01522 516717
Email: HMCoroner_Southlincolnshire@lincolnshire.gov.uk

04 DEC 2015

General Council

Private and Confidential

Professor ARW Forrest

HM Senior Coroner for South Lincolnshire
Unit 1

Gilbert Drive

Endeavour Park

Boston PE21 7TQ
“Chie ref: SP/6-1-2014/110

Your ref: ARWF/FMW S.25.14 — 00025-2014

03 December 2015

Dear Professor Forrest

Action to Prevent Future Fatalities
(Inquest into the death of Charles Pierson)

| write further to my letter dated 6 October 2014 to info itcome
of the GOC’s investigation into the fitness to practise of

The allegation against has now been considered by two of the
GOC’s case examiners.

When the case examiners consider an allegation of impaired fitness to
practise against a registrant, they are required to apply what is known as the
“realistic prospect test” in order to determine whether or not a matter should
be referred for a hearing before the Fitness to Practise Committee. This is a
' two stage test:

e Firstly, the case examiners must seariekdey whether there is a realistic
prospect of being able to prove the facts alleged against the registrant
if the allegation is referred to the Fitness to Practise Committee.

e Secondly, if the alleged facts were proved, the case examiners must
consider whether they are so significant as to indicate that the
registrant's fitness to practise is or may be impaired to a degree that
justifies action being taken against their registration.

The case examiners have applied this test to the allegation against

and have determined that the matter ought not be referred to the Fitness to
Practise Committee. The case soainst AME tas therefore now been
closed with no further action.

As the case did not proceed to a final hearing, the full decision of the case
examiners is not publically available. The GOC can consider disclosing the
decision to you however, if a specific request is made. If you would like to

obtain a copy of the full decision, please submit your request by email to

Telephone +44 (0)20 7580 3898
Fax +44 (0)20 7436 3525

Email goc@optical.org

Web www.optical.org

Registered charity number 1150137

Finally, you may recall that in my letter of 6 October 2014 | informed you that
we were looking at the issues raised by this case from the perspective of our
role in setting standards for the individuals and businesses on our register. |
can now inform you that the new standards for individual registrants have
since been published and are available On our website:
https:/Awww.optical.org/en/Standards/. These define the standards of
behaviour and performance we expect of all registered optometrists and
dispensing opticians, including students. It is hoped that by making clear what
we expect of our registrants, these standards will have a positive impact on
the quality of care provided to patients.

| hope the above information is of some assistance. Please do not hesitate to
contact me if you require any further information.

Yours sincerely,

Samantha Peters

Chief Executive and Registrar