Prevention of Future Deaths reports · 2014
Regulation 28 report to prevent future deaths, reference 2014-0459, written 23 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 | 23 Oct 2014 |
|---|---|
| Reference | 2014-0459 |
| Deceased | Sonielia Holmes |
| Coroner | Thomas Osborne |
| Coroner area | Bedfordshire & Luton |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| Organisation named | Bedford Hospital NHS Trust |
| Source | judiciary.uk record · original PDF |
| Responses published | none published |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
Thomas R Osborne
Senior Coroner for Bedfordshire and Luton
REGULATION 28: REPORT TO PREVENT FUTURE DEATHS
THIS REPORT IS BEING SENT TO:
Mr Stephen Conroy
Chief Executive
Bedford Hospital NHS Trust
Kempston Road
Bedford
MK42 9DJ
CORONER
I am Thomas R Osborne, Senior Coroner for Bedfordshire and Luton
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.
http://www.legislation.gov.uk/ukpga/2009/25/schedule/5/paragraph/7
http://www.legislation.gov.uk/uksi/2013/1629/part/7/made
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INVESTIGATION and INQUEST
On 10th May 2013 I commenced an Investigation into the death of Sonielia
Laura Caya HOLMES, aged 23 years . The Investigation concluded at the end
of the inquest on 21st October 2014. The Conclusion of the Inquest was a
Narrative Conclusion: Sonielia Laura Caya HOLMES was admitted to Bedford
Hospital on 17th April 2013 suffering from confusion and seizures; she had a
history of tonsillitis for the previous two weeks. She was eventually diagnosed
with Haemophagocytic Syndrome on 2nd May 2013 following a fall which, as a
result of her blood disorder, caused a bleed in her brain. The brain injury
resulted in a lost opportunity to treat her underlying condition and she
deteriorated and died from Multi Organ Failure at 17:06 hours on 4th May 2013.
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CIRCUMSTANCES OF THE DEATH
The Deceased was taken to Bedford Hospital South Wing on 17th April 2013
suffering acute confusion and seizures. She was very unwell and taken to the
Critical Care Complex the following day. She had mixed clotting abnormalities
Senior Coroner, The Court House, Woburn Street, AMPTHILL, Bedfordshire, MK45 2HX
Tel 0300-300-6559 | Fax 0300-300-8267
and was ventilated and treated. She was returned to Ward on 22nd April 2013.
She deteriorated again and got out of bed on 2nd May 2013 and fell over. A CT
scan revealed extra cranial and intracranial injuries. She was taken back to the
Critical Care Complex, ventilated again and had a repeated CT scan. A referral
to Addenbrooke's Hospital and The National Centre for Neurology in London
was made, but both stated that she was not suitable for further intervention. Her
pupils had become fixed and she died whilst still receiving supportive treatment.
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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. That on numerous occasions it proved impossible for the doctors
attending Miss Holmes to contact the Haematology Department at the
Hospital. This was despite the staff using all known contact details,
including mobile phones and bleep numbers.
2. That the Haematologists working within the Hospital failed to respond to
messages left for them to offer advice and to review Miss Holmes.
3. It was apparent from the evidence that Haematology is a vital service
within the Hospital and any failure to respond to requests for assistance
from other clinicians will put lives at risk.
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ACTION SHOULD BE TAKEN
In my opinion action should be taken to prevent future deaths and I believe you,
as the Chief Executive of Bedford Hospital NHS Trust, have the power to take
such action.
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YOUR RESPONSE
You are under a duty to respond to this report within 56 days of the date of this
Report, namely by the 11th December 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.
Senior Coroner, The Court House, Woburn Street, AMPTHILL, Bedfordshire, MK45 2HX
Tel 0300-300-6559 | Fax 0300-300-8267
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COPIES and PUBLICATION
I have sent a copy of my Report to:
the Chief Coroner
and to the following Interested Persons:
– Mother
I 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.
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Dated 23rd October 2014
…………………………….
Thomas R Osborne
Senior Coroner
Bedfordshire and Luton
Senior Coroner, The Court House, Woburn Street, AMPTHILL, Bedfordshire, MK45 2HX
Tel 0300-300-6559 | Fax 0300-300-8267
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