Prevention of Future Deaths reports · 2014
Regulation 28 report to prevent future deaths, reference 2014-0439, written 8 Oct 2014. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 8 Oct 2014 |
|---|---|
| Reference | 2014-0439 |
| Deceased | Chloe Siokos |
| Coroner | Andrew Walker |
| Coroner area | London (North) |
| Category | Other related deaths |
| 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.
a North London Coroners Court, Her Majesty's Coroner for the 29\Wood Stee, Northern District of Greater London Bamet ENS 4BE (Harrow, Brent, Barnet, Haringey and Enfield) Telephone 0208 447 7680 Fax 0208 447 7689 REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: Department of Health Richmond House 79 Whitehall London SWI1A 2NS CORONER lam Andrew Walker, senior coroner, for the coroner area of Northern District of Greater London 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 25" June 2012 | opened an inquest touching the death of Chloe Siokos, 80 years old. The inquest concluded on the 29" July 2014. The conclusion of the inquest was “Unlawful Killing”, the medical case of death was 1a Incised wound to the throat and blunt force trauma to the head. 4 | CIRCUMSTANCES OF THE DEATH On the twenty second of January 2013 Chloe Siokos was found in a kitchen at her home having been killed by her husband who had set a fire in the house before hanging himself. There were 3 relevant factors :- That Mrs Siokos shared a home with Mr Siokos. That Mrs Siokos was subject to a pattern of abuse by Mr Siokos over a number of years. That Mr Siokos had, at some point, begun to suffer a deterioration in mental health leading to a delusional state of mind. Mr Siokos had no history of psychiatric illness and he never showed any psychotic ideation. On the 16'" January 2013 the GP telephoned to speak to Mr Siokos but spoke to Mrs Siokos instead. Mrs Siokos asked the doctor if it was about the results of the X-ray that was undertaken on the 11" January 2013. The doctor explained that it was. Mrs Siokos then called for Mr Siokos to come down from upstairs, the portion of the house where he lived separate from Mrs Siokos, The doctor explained that there was a problem | | | | | i a ee RES oe Her Majesty’s Coroner for the * Northern District of Greater London (Harrow, Brent, Barnet, Haringey and Enfield) with the X-ray and that Mr Siokos would need to be seen urgently the following day. Mr Siokos then asked the doctor to speak to Mrs Siokos again and it was agreed that Mrs Siokos would bring him in to see a different doctor . Concerns were raised at the inquest about whether in the circumstances, that Mr and Mrs Siokos lived separately at the same address, had separate door bells and Council Tax and largely lived separate lives an interpreter should have been used. Concerns were also raised that when looking at Mr Siokos’s GP notes there was no flag to indicate that it may not be appropriate to use Mrs Siokos as an interpreter for Mr Siokos. Mrs Siokos did accompany Mr Siokos to that appointment and again assisted with interpreting what was said. 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. — That there was no framework for primary care staff to make a decision when an interpreter is required. That interpreters should be available to primary care staff more readily That there is no system of flagging to alert primary care staff to the need to consider the care provided to a patient in the context of another patient where that is relevant. 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 the 2™ December 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 Her Majesty’s Coroner for the Northern District of Greater London (Harrow, Brent, Barnet, Haringey and Enfield) Persons;- Members of the family , 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. Yqu may make representations to me, the coroner, at the time of your response, about}thefelease or the publication of your response by the Chief Coroner. 8" October 20
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