Prevention of Future Deaths reports · 2014
Regulation 28 report to prevent future deaths, reference 2014-0441, written 13 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 | 13 Oct 2014 |
|---|---|
| Reference | 2014-0441 |
| Deceased | George Vickery |
| Coroner | David Horsley |
| Coroner area | Portsmouth & South East Hampshire |
| Category | Hospital Death (Clinical Procedures and medical management) 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.
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:
Mrs Katrina Percy
Chief Executive, Southern Health NHS Trust
Sterne 7
Tatchbury Mount
Calmore
Southampton SO40 2RZ
1 | CORONER
| am David Clark Horsley, senior coroner for the coroner area of Portsmouth and South
East Hampshire.
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 28" March 2013 | commenced an investigation into the death of George Robert
Vickery, aged 89. The investigation concluded at the end of the inquest on 6"" October
2014. The conclusion of the inquest was: Death due to an Accident.
4 | CIRCUMSTANCES OF THE DEATH
George Vickery fell after alighting from an ambulance outside the Oak Park Community
Clinic, Havant. He was attending the clinic for leg treatment. He sustained a broken hip
and was taken to Queen Alexandra Hospital in Portsmouth, where he died the next 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. —
That the decision to treat Mr Vickery at the clinic rather than in his own home (as had
been the case previously) was taken without regard to a request from his GP that he
should be treated at home, not at a clinic.
In my opinion, when assessing how and where a patient should be treated, or when
assessing whether any changes should be made as to how and where a patient is
treated, Southern Health's Integrated Community Services should formally consult with
the Patient's GP and have proper regard to the GP's views on these matters.
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 8" 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
Persons:
- Mr Vickery's son,
- Mr Vickery's GP,
| 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.
13" October 2014 {si RONER]
"4@
David Clark Horsley
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