Prevention of Future Deaths reports · 2015
Regulation 28 report to prevent future deaths, reference 2015-0043, 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 | 2015-0043 |
| Deceased | Paul Moroney |
| Coroner | John Pollard |
| Coroner area | Manchester South |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
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 REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: The Chief Executive, Tameside Hospital Foundation NHS Trust. 1 | CORONER | am John Pollard, senior coroner, for the coroner area of South Manchester 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 3% September 2014 | commenced an investigation into the death of Paul Moroney dob 7" November 1961. The investigation concluded on the 21% January 2015 and the conclusion was one of “He died from the abuse of alcohol”. The medical cause of death was 1a Dilated Cardiomyopathy 1b Chronic Alcoholism 11. Liver Cirrhosis and Steatosis 4 | CIRCUMSTANCES OF THE DEATH On the 27" August 2014 he attended at Tameside Hospital by ambulance . the ambulance proceeded to the hospital with full emergency equipment in operation, and the patient was given oxygen in the ambulance. Once at the hospital blood was taken and a bed-side X-ray was done. There was concern that he had had a blood clot, and it was arranged that he should return to the hospital the following day for the administration of blood thinning agents. Shortly after returning home, his breathing got worse and a second emergency ambulance was called. The ambulance staff asked the patient why he had discharged himself from hospital and he told them that he had been discharged by the doctors. 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. Whilst at the hospital on the first occasion, no oxygen saturations were monitored or recorded 2. Having been put on oxygen in the hospital, this was discontinued and he was sent home without his Oxygen saturations being monitored 3. When he was re-admitted to the hospital there was no record available to the staff about his previous oxygen levels. ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and | believe you 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 1* April 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 Persons rant) RR (roth of the deceased). | 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 senga cppy of this report to any person who he believes may find it useful or of interest. Yow may make representations to me, the coroner, at the time of your response, about lease or the publication of your response by the Chief Coroner. 04.02.15 John Pollard, HM Senior Coroner
1 response published against this report on judiciary.uk. A response is a body's written reply to the coroner's concerns; publication is at the discretion of the Chief Coroner's office, so an absent response does not mean nobody replied.
Chief Executive Office Silver Springs Tameside General Hospital Ashton-Under-Lyne OL6 9RW Our Ref: | | Date: 31 March 2015 Mr Pollard Senior Coroner Coroner’s Court 1 Mount Tabor Street Stockport SK1 3AG Dear Mr Pollard Paul Moroney (Deceased) Tameside Hospital INHS| NHS Foundation Trust | write further to your letter dated 4 February 2015 enclosing a Regulation 28 Report issued at the conclusion of the inquest into the death of Paul Moroney, which took place on 21 January 2015. | am very sorry that you found cause to issue this report and | hope to address the concerns raised to your satisfaction in this letter. | note that during the course of the inquest you had three areas of concern. As the Trust were not legally represented at the inquest | am sorry we were not able to provide clarity at the time. | have addressed the concerns as set out in Section 5 of your Regulation 28 Report as follows: 1. Whilst at the hospital on the first occasion, no oxygen saturations were monitored or recorded. On 27 August 2014, the patient was taken by ambulance to Tameside Hospital. The patient's saturations were recorded as 70% on oxygen on 15LPM. The nursing records then indicate the following: At 10:41 am, the patient's oxygen saturation levels were recorded as 98% on 15LPM of oxygen which is equal to a NEWS score of 0. At 11:30am, the patient's oxygen saturation levels were recorded as 100% on 15LPM of oxygen which is equal to a NEWS score of 0. At 12:22, the patient's oxygen saturation levels were recorded as 100% on 15LPM of oxygen which is equal to a NEWS score of 0. The patient was then discharged at 13:17pm by Dr Pattrick, Consultant in Acute Medical Unit with in-reach to Emergency Medicine. | hope that this reassures you that the oxygen saturations were monitored and recorded. | can only apologise that the position in respect of the monitoring of the patient's oxygen saturation levels was not fully communicated with the family, nor demonstrated to you at the inquest. A copy of the notes referred to are enclosed for your consideration. Tameside Hospital NHS) NHS Foundation Trust Should you have any further questions arising from the contents of this letter please do not hesitate to contact me. | am again sorry that your investigation into this death caused you such significant concern to issue a Rule 28 letter but | hope that you now suitably reassured. Yours sincerel Director of Nursing On behalf of Karen James, Chief Executive
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