Prevention of Future Deaths reports · 2014
Regulation 28 report to prevent future deaths, reference 2014-0376, written 11 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 | 11 Aug 2014 |
|---|---|
| Reference | 2014-0376 |
| Deceased | Aaron Vranas |
| Coroner | Tom Osborne |
| Coroner area | Bedfordshire & Luton |
| 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.
REGULATION 28: REPORT TO PREVENT FUTURE DEATHS (1) NOTE: This form is to be used after an inquest. | THIS REPORT IS BEING SENT TO: MR JOHN ROOKE CHIEF EXECUTIVE BEDFORDSHIRE CLINICAL COMMISSIONING GROUP CAPABILITY HOUSE WREST PARK i SILSOE po BEDFORDSHIRE MK45 4HR 1 | CORONER I am Mr Tom OSBORNE, Senior Coroner for the Coroner Area of | Bedfordshire and Luton. | | 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. Hl | |3 | INVESTIGATION and INQUEST On the i4t April 2014 I commenced an Investigation into the death of Aaron Michael VRANAS aged 25 years. The Investigation concluded at the end of the Inquest on 28t* July 2014 at which I recorded “suicide whilst | suffering from a mental illness”, the medical cause of death being : | I (a) Multiple Injuries 4 | CIRCUMSTANCES OF THE DEATH On the 13 April 2014 Aaron Michael VRANAS fell from a 10% Floor window at Bury Court, Church Lane, Bedford, when he received fatal multiple injuries. “TO 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: Matters of concern are | i 1. a me that it would be in the best interests of | | the patients if the treatment of the psychiatric illness and the patient's ADHD (Attention Deficit Hyperactivity Disorder) were dealt with at the same Hospital as it is difficult to manage a patient when their treatment is carried out in two entirely different hospitals many miles apart. He went on to say in evidence that he had argued for that change many times in the past, but to no avail. | ACTION SHOULD BE TAKEN i In my opinion action should be taken to prevent future deaths and I believe you, as the Chief Executive, 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 6t October 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 Person(s): Sally Morris, Chief Executive, SEPT; Family 1 i L 1 am also under a duty to send the Chief Coroner a copy of your response. The Chief Coroner may publish either or both, ina 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. | The Chief Coroner may publish either or both, ina 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. Dated this 11% day of August 2014 oeccedoccecsovcsectecedees Tom OSBORNE Senior Coroner Bedfordshire & Luton
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.
Bedfordshire Clinical Commissioning Group Bedfordshire Clinical Commissioning Group Suite 1, Capability House Mr Tom Osborne Wrest Park Coroner Silsoe HM Coroner's Office edfordshire MK45 4HR The Court House — 6 Woburn Street Website: www.bedfordshireccg.nhs.uk Ampthill ; Bedfordshire MK45 2HX ZS ee 29 September 2014 Dear Mr Osbourne, RE: Inquest touching the death of Aaron Michael VRANAS Ryan Inquest held on 28% July 2014 at Coroners Court Ampthill Regulation 28 report Thank you for your letter dated 15"" August 2014 in relation to this very sad case. It is Bedfordshire Clinical Commissioning Group's intention that people with Attention Deficit Disorder (ADHD) will be supported through local services. This is being considered currently, as part of the procurement of mental health services in Bedfordshire, which is due to be completed by April 2015. In the interim period, Bedfordshire Clinical Commissioning group will work with South Essex Partnership Trust on the development of a pathway that clearly outlines the responsibilities for safe and effective care of people that have a diagnosis of ADHD and a psychiatric illness and are in receipt of services from local and specialist services. This will be completed by end of October 2014. | hope this addresses your concerns in relation to the findings of this case, if you require any further details | will be happy to provide these for you. “Yours sincerely Chief Operating Officer Bedfordshire Clinical Commissioning Group r 38 SEP SE better care, better value, better health
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