Prevention of Future Deaths reports · 2014
Regulation 28 report to prevent future deaths, reference 2014-0384, written 26 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 | 26 Aug 2014 |
|---|---|
| Reference | 2014-0384 |
| Deceased | Iris Grimwood |
| Coroner | ARW Forrest |
| Coroner area | South Lincolnshire |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| Organisation named | United Lincolnshire Teaching Hospitals NHS Trust |
| Source | judiciary.uk record · original PDF |
| Responses published | none published |
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.
AR W Forrest tum, rrep, 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: iB Acting Chief Nurse, United Lincolnshire Hospitals NHS Trust, Lincoln County Hospital, Lincoln, LN2 5QY CORONER | am ARW Forrest, Senior Coroner for the Coroner's area of South Lincolnshire. 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. INVESTIGATION and INQUEST On 16" October 2013 | commenced an investigation into the death of Iris May GRIMWOOD, age 80. The investigation concluded at the end of the inquest on 22 August 2014. The conclusion of the inquest was NATURAL CAUSES. Lads CIRCUMSTANCES OF THE DEATH Iris was well for her age, apart from dizziness for some 14 years which had been treated with prochlorperazine. When this drug was stopped her condition deteriorated. She developed a tremor which became more prominent after July 2013. From then on her condition deteriorated and she went down hill. Drug induced Parkinsonism contributed to her symptoms in the early stages of her illness. Lewy body dementia was thought to be a cause when she developed visual hallucinations. Concerns were expressed about the quality of nursing care during her decline, but no evidence presented suggested that this contributed to her death. She died in Pilgrim Hospital on 8th October 2013 as a result of her progressive neurological disease. Unit 1, Gilbert Drive, Endeavour Park, Boston PE21 7TQ Tel: 01522 553374 Fax: 01522 516717 Email: HMCoroner_Southlincolnshire@lincolnshire.gov.uk AR W Forrest iu, rrcp, 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. — . 41 Evidence from medical staff at Pilgrim Hospital and members of Iris's family included expressions of concern that there were difficulties in providing the level of nursing care that Iris needed. Evidence was also given that mistakes were made in the use of semi-automatic thermometers for measuring body temperature and an episode was described where a nurse attempted to apply an antifungal ointment to Iris's genital region, this having been prescribed for the treatment of oral thrush, before being stopped by a family member. The medical staff attributed these problems to less than optimal numbers of nursing staff, compounded by difficulties in recruitment and retention of nursing staff as well as problems with funding training. 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 20" 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. COPIES and PUBLICATION | have sent a copy of my report to the Chief Coroner and to the following Interested Persons: 1. Quality Care Commission, Citygate, Gallowgate, Newcastle upon Tyne, NE1 4PA Unit 1, Gilbert Drive, Endeavour Park, Boston PE21 7TQ Tel: 01522 553374 Fax: 01522 516717 Email: HMCoroner_Southlincolnshire@lincolnshire.gov.uk AR W Forrest tum, 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. 26" August 2014 ( 4 Soe ARW Forrest isccssccisivsedsiesicargeceScascossceseesswanteccaceesscacechcaveses 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
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