Prevention of Future Deaths reports · 2014
Regulation 28 report to prevent future deaths, reference 2014-0497, written 12 Nov 2014. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 12 Nov 2014 |
|---|---|
| Reference | 2014-0497 |
| Deceased | David Ince |
| Coroner | Sian Jones |
| Coroner area | Preston & West Lancashire |
| Category | Community health care and emergency services related deaths |
| Organisation named | North West Ambulance Service NHS Trust · Lancashire Teaching Hospitals NHS Foundation 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.
ANNEX A
REGULATION 28: REPORT TO PREVENT FUTURE DEATHS (1}
REGULATION 28 REPORT TO PREVENT FUTURE DEATHS
THIS REPORT IS BEING SENT TO:
Acting Head of Legal Services
North West Ambulance Service NHS Trust
CORONER
| am Sian Jones assistant coroner, for the coroner area of Preston and West Lancashire
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 27 June 2014 | commenced an investigation into the death of David Anthony Ince.
The investigation concluded at the end of the inquest on 23rd October 2014. The
conclusion of the inquest was
medical cause of death
1(a) Hypoxic-ischaemic encephalopathy
1(b) Cardiac arrest (resuscitated)
14(c) Ischaemic heart disease
and narrative conclusion
David Anthony Ince was admitted by ambulance to Royal Preston Hospital at 00.06 on
26/06/14 having suffered a collapse at home. The clinical history and investigations
suggested that the event was a syncopal episode of the sort Mr Ince had been suffering
for some months. He was discharged in the early hours but shortly after having arrived
home, he suffered a cardiac arrest which was unsurvivable despite readmission to
hospital.
CIRCUMSTANCES OF THE DEATH
See narrative conclusion above.
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. —
4) In the course of the Inquest hearing, it became apparent that the NWAS electronic
record referred to an ECG having been carried out on Mr Ince by the ambulance staff at
11.35pm, prior to his first admission to A&E. However the fact of an ECG and its
relevant features was not recorded in the notes of the A&E nurse who received the
verbal handover from NWAS personne! on arrival at RPH, and no ECG trace was
handed over or seen by A&E staff.
(2) It was the evidence of the Middle Grade doctor in Emergency Medicine, who had
subsequently assessed and treated Mr Ince in the A&E department, that NWAS staff
often have to be asked for ECG traces which they have obtained on patients, and will
often have to return to their vehicles to get them, rather than handing them over to A&E
staff as a matter of course when delivering patients to the department.
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 7th January 2015. |, 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
ee (the deceased's widow) Head of Clinical
Case Management at Lancashire Teaching Hospitals NHS Foundation Trust.
| 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.
Date {Z /\ /**
Stan S Jones
Assistant Coroney\
Preston and West Lancashire
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