Prevention of Future Deaths reports · 2015
Regulation 28 report to prevent future deaths, reference 2015-0041, written 4 Feb 2015. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 4 Feb 2015 |
|---|---|
| Reference | 2015-0041 |
| Deceased | Paul Hardy |
| Coroner | Stephanie Haskey |
| Coroner area | Nottinghamshire |
| Category | State Custody related deaths |
| Organisation named | Nottingham University 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.
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: 1. Offender Health Directorate Nottinghamshire Healthcare NHS Trust Westminster House The Wells Road Nottingham 1 | CORONER lam Miss Stephanie Haskey, Assistant Coroner, for the Coroner area of Nottinghamshire 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 The death of Paul Hardy was subject to an Inquest from 3-12 November 2014 4 | CIRCUMSTANCES OF THE DEATH Paul Hardy was a serving prisoner at HMP Lowdham Grarige, operated by Serco, when he was confirmed by his local hospital as suffering from urological cancer. Whilst this was not, in the end, the immediate cause of his death, there were delays and errors in process whilst he was under the care of Lowdham Grange which caused unnecessary suffering and distress. 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: 1. That there was a clear failure by Healthcare Staff to act upon instruction given by a visiting Advanced Nurse Practitioner to obtain and process blood and urine samples for the investigation of possible urological cancer. 2. There was a failure to act upon a clear recommendation made by the Prison and Probation Ombudsman’s Clinical Reviewer for facilitating the effective obtaining of blood samples for INR monitoring. 3. There was a failure to act upon a clear recommendation made by the Clinical Reviewer that there should be a Significant Event Analysis of the events surrounding the death of Paul Hardy. 6 | ACTION SHOULD BE TAKEN in my opinion action should be taken to prevent future deaths and | believe your organisation has the power to take such action. 7 | YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely 4° February 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. 8 | COPIES and PUBLICATION | have sent a copy of my report to the Chief Coroner and to the following Interested Persons: —_ as — of HMP Lowdham Grange Nottingham University Hospitals NHS Trust who may find it useful or of interest. | 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. 9 | [DATE] a [SIGNED BY CORONER] ~y Lt fee Z= FS Stephanie Haskey
See every Prevention of Future Deaths report matching Nottingham University Hospitals NHS Trust, and how often a new one appears.
What would an alert for this have sent me? Search the full text
Free to try — the preview shows the real matches and how many arrived in the last 12 months. Your first email alert is free.
These reports are published by the Chief Coroner's office at judiciary.uk and are © Crown copyright. The text here is reproduced from the published PDF so it can be searched. If something on this page is wrong, or you are a person named in it and want it reviewed, email drcjar@gmail.com and we will act promptly.