Prevention of Future Deaths reports · 2014
Regulation 28 report to prevent future deaths, reference 2014-0363, written 6 Aug 2014. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 6 Aug 2014 |
|---|---|
| Reference | 2014-0363 |
| Deceased | Vivian Hunt |
| Coroner | Andrew Barkley |
| Coroner area | Powys, Bridgend and Glamorgan |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
Text recovered by OCR from a scanned PDF. OCR is imperfect: check anything you rely on against the source PDF. Reproduced verbatim, including the scan's own layout.
ANNEX A
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. The Chief Executive Cwm Taff Health Board
2. Chief Coroner
1 | CORONER
| am Andrew Roger Barkley, Senior Coroner, for the coroner area of Powys, Bridgend
and Glamorgan Valleys
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 the 4" April 2014 | commenced an investigation into the death of Vivian Herbert
HUNT aged 84. The investigation concluded at the end of the inquest on 6” August
2014. The conclusion of the inquest was that Mr Hunt had died from the effects of a
subdural haemorrhage following an un-witnessed fall he had in his hospital room on 3"
_| April 2014.
4 | CIRCUMSTANCES OF THE DEATH
Mr HUNT was a patient on the Mental Health ward of the Royal Glamorgan Hospital
when he was found to have fallen in his room in the early hours of the morning of 3
April 2014 sustaining an injury to the side of his face. He had fallen in similar
circumstances the day before. Throughout the day he deteriorated until he became
unresponsive and a subsequent CT scan showed a bleed on his brain from which he
later died the following day.
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) Despite the fall he suffered on 2" April and despite suffering a clear injury to his
face in the fall on 3" April 2014, no neurological observations were made of him
between 5am on 3” April and between 12:30 and 13:15pm that day.
6 | ACTION SHOULD BE TAKEN
In my opinion action should be taken to prevent future deaths and | believe you and 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 3" 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.
8 | COPIES and PUBLICATION
| have sent a copy of my report to the Chief Coroner who may find it useful or of interest.
{ 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 | 6" August 2014 SIGNED: A. fovsg
a
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.
, I f Bwrdd lechyd Prifysgol Cwm Taf University Health Board Mr Andrew Barkley HM Coroner for Cardiff and the Vale of Glamorgan Aberdare Police Station Cross Street Aberdare CF447EG 01443 743698 Dear Mr Barkley, Re: Regulation 28 Coroner's Rules Vivian Herbert Hunt (died 4th April 2014) 01443 744800 2nd October 2014 I refer to your email correspondence sent on 6th August 2014, enclosing the Regulation 28 report, which details the areas of concern following your 6th conclusion of the inquest on August 2014 touching on the death of Mr Vivian Herbert Hunt on 4th April 2014. Please be assured that the Health Board has taken this matter extremely seriously and has learnt lessons following investigation and the matters raised at the inquest into the circumstances. Robust action has been to taken to minimise the risk of any recurrence. 1. Action taken to plan and monitor improvements A corrective Action Plan for Improvement was developed to ensure effective action; this is attached. 2. Actions implemented I can confirm that the actions have been taken forward by the Mental Health Directorate with to compliance with neurological investigations post head injury; actions still in progress will be monitored through to completion by the Health Board's governance groups. The progress made by 29th September 2014 is reflected in the updated plan as attached. regards I sincerely hope that this information and enclosed Action Plan will reassure you that the Health Board has learnt important lessons from the investigation into the care provided to Mr Hunt and that effective action has now been taken to prevent future deaths. RECEIVED $ hi!g Cwm Tat WA L ES NHS University Health Board Bwrdd lechyd Prifysgol I would like to convey once again my deepest sympathy and sincere apologies to Mr Hunt's family for the failings identified. If you require any additional information or clarification please do not hesitate to contact me. Yours sincerely ~ P Mrs AJ Williams ) Chief Executive Officer Cwm Taf University Health Board
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