Prevention of Future Deaths reports · 2014
Regulation 28 report to prevent future deaths, reference 2014-0352, written 31 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 | 31 Jul 2014 |
|---|---|
| Reference | 2014-0352 |
| Deceased | John Shelley |
| Coroner | Jonathan Layton |
| Coroner area | Carmarthenshire & Pembrokeshire |
| 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 REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: 1. Chief Executive of Hywel Dda University Health Board Withybush General Hospital Fishguard Road Haverfordwest SA61 2PZ 1 CORONER I am Jonathan Mark Layton senior coroner, for the coroner area of Carmarthenshire and Pembrokeshire. 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 18th July 2013 I commenced an investigation into the death of John Keith William Shelley then aged 68. The investigation concluded at the end of the inquest on 31 July 2014. The conclusion of the inquest was a narrative conclusion namely that the deceased had died on the 14th July 2103 from lobar pneumonia resulting from the ingestion of fairy liquid. The medical cause of death was: 1(a) lobar pneumonia 4 CIRCUMSTANCES OF THE DEATH (1) John Keith William Shelley who had suffered brain injury at birth was wholly dependent upon the care of others. (2) Following an assessment of his needs he was accommodated in a residential care home by the Health Board. (3) Given his propensity to drink any liquids, certain steps were taken to try to prevent Mr Shelley consuming harmful substances. (4) Despite this he was able to obtain and consume a quantity of fairy liquid from a bottle placed near to the kitchen window. (5) Having consumed the fairy liquid he quickly became ill. (6) There was a significant delay before advice was sought. The full extent of Mr Shelley’s illness was not adequately communicated to the person from whom advice was sought. Thus an inadequate assessment of the situation was made. (7) Despite clear signs of Mr Shelley’s deteriorating health no contact was made with emergency services for some time. 5 CORONER’S CONCERNS During the course of the inquest the evidence revealed this matter 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. 1 The MATTERS OF CONCERN is as follows: That staff employed by the Health Board in caring roles should undertake basic first aid training and receive regular up-dates. There was information before the inquest that some staff at the residential unit had received no basic life support training and in relation to other staff members it was out-of-date. 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 the 25 September 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: 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 31 July 2014 Signed: J M Layton 2
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.
‘ GIG Bwrdd lechyd Prifysgol 4 NHS Hywel Dda University Health Board ‘Swyddfeydd Corfforaethal, Adeilad Ystwyth Hafan Derwen, Parc Dewi Sant, Heol Ffyanon Job Caerfyrddin, Sir Gaerfyrddin. SA31 3BB en oytiOur ret. nnweh am/Please ask for: Rhif fon ‘Telephone: Ftacs/Facsimiie: Comorate Offices, Ystwyth Building Hafan Derwen, St Davids Park, Job’s Well Road, Carmarthen, Carmarthenshire, SA31 3BB E-bosvE-mail: Dyddiad/Date: 24" September 2014 Solicitor for H.M Senior Coroner, Coroner’s Office, Town Hall, Milford Haven, Pembrokeshire, SA73 3]W Dear Sir Inquest regardi h ith of Joh ith iam Shell I write further to your letter of 31% July 2014, pursuant to Regulation 28 of the Coroners (Investigations) Regulations 2013. In terms of the issues raised in your letter we believe it would assist to differentiate between professionally qualified staff and support workers. Firstly, we have programs in place to train all our professionally qualified staff in Immediate Life Support/Basic Life Support training which comprises the recognition and response to the acutely unwell patient and includes response to cardiac arrest. Moving on to the second group of staff, our Healthcare Support Workers, who comprise the majority of the staff employed in this residential unit; they have not routinely been trained in Basic Life Support or “first aid”. Although if this had been requested and subject to capacity, this could be undertaken. This has been because the focus of the Simulation & Resuscitation Team has been to deliver training directly to all clinical staff annually within the Health Board. Risk assessments approved by the Health Board Resuscitation Committee have resulted in prioritising the training to high risk areas. However, since this tragic event all the staff in the residential units have been trained in Basic Life Support. Bwrdd lechyd Prifysgol Hywel Dda yw enw gweithredol Bwrdd lechyd Lleo! Prifysgol Hywel Dda Hywei Dda University Heaith Board is the operational name of Hywel Dda University Local Health Board Mae Bwrdd lechyd Prifysgol Hywel Dda yn amgyichedd di-fwg Hywel Dda University Health Board operates a smoke free environment In terms of moving further forwards, we have aiso looked at other options which may be available for healthcare support staff, where this would be appropriate. We are evaluating options for training these staff groups to target “life threatening conditions”. We feel that a specifically targeted approach to life threatening conditions will provide the best type cover and will be more specific than a generalised first aid course. This course will include recognition & response to life threatening conditions i.e. heart attack, choking, serious bleeding including cardiac arrest and is recognised by The British Heart Foundation. We will be taking a risk based approach to determine which staff will require this level of training, which will include if they will be working unsupervised i-e. without the direct support of trained clinical staff. Should you have any queries please don’t hesitate to contact me. Yours sincerely Karen pexecuth f chiey x xecutive
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