Prevention of Future Deaths reports · 2015
Regulation 28 report to prevent future deaths, reference 2015-0090, written 11 Mar 2015. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 11 Mar 2015 |
|---|---|
| Reference | 2015-0090 |
| Deceased | Bradley Griffiths |
| Coroner | Catherine Mason |
| Coroner area | Leicester (City & South) |
| Category | Child Death (from 2015) |
| 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.
for Leicester (City and South) REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT 10: [EEE Associate Director of Operations, Integrated Children’s Services, Coventry CORONER | am Catherine Mason, Senior Coroner for Leicester (City and South) 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. http://www. legislation.gov.uk/ukpga/2009/25/schedule/5/paragraph/7 http://www. legislation.gov. uk/uksi/2013/1629/part/7/made INVESTIGATION and INQUEST On 28/11/2012 | commenced an investigation into the death of Bradley David Griffiths, who was 7 months old. The investigation concluded at the end of the inquest on 11 March 2015. The medical cause of death was 1a) Hypoxic Ischaemic brain injury following cardiorespiratory arrest, cause undetermined 2) Two previous Apparent Life-Threatening Events; Brainstem inflammation. The conclusion of the inquest was Open conclusion CIRCUMSTANCES OF THE DEATH Bradley Griffiths died on the 18th November 2012 at the Leicester Royal Infirmary following a cardiac arrest at home on the 13th November 2012. He was initially admit to Walsgrave Hospital Coventry where attempts to resuscitate continued until spontaneous circulation occurredHe was transferred to the Leicester Royal Infirmary Paediatric Intensive Care Unit the same day. His prognosis was poor and intensive care was withdrawn on the 18” November 2012 at 13:28hours and he died at 13:45hours. Bradley had suffered two previous Apparent Life-Threatening Events; one on the 7th November 2012 and the other on the 11th November 2012. Both resulted in hospital admissions for a period of observation during which he was found to be well enough to be discharged. Clinical evidence has not provided insight into why the fatal cardiac arrest occurred. Therefore, the cause of it remains undetermined 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 Evidence was heard from [IIE wo was Bradley's Health Visitor. | explained that she only saw Bradley once which was for the birth visit on the 30th April 2012 Although two appointments were made with Bradley's Mum for the 6 week routine check to take place, his Mum did not keep them. After the second failed appointment IEEEtelephoned Bradley's Mum on the 26th June 2012 and was informed by her that she had separated from Bradley's father and she and Bradley were living in the Northampton are with friends and that she had registered with a new G.P. Howe’ uld not tell a she was living or the details of the new GP. As a result nt Bradley's records to the “No Trace” storage at the Child Health Department with the expectation they would be sent to the next assigned Health Visitor. Town Hall Square, Leicester, LEL 9BG Vel 0116 4541030 | Fax 0116 225 2537 6 | 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 06 May 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 University Hospitals Coventry and Warwickshire, pt a Mr and EEE MERE ect the LOCAL SAFEGUARDING | 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-efyou ponse by the Chief Coroner. | Dated 11 a ; for Leicester (Cityand South) Town Hall Square, Leicester, LE Tel 0116 4541030 | Fax 0116225
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.
Coventry and Warwickshire Partnership NHS Trust Our Ref: SG/PM/AJJ 1 September 2015 Ms Catherine Mason Senior Coroner for Leicester (City & South) Coroner's Court Office Coroner's Court Town Hall Town Hall Square LEICESTER LE1 8BG Dear Ms Mason Re: Master Bradley David Griffiths Thank you for the Regulation 28 Report to Prevent Future Deaths (PFD) following the inquest into the death of Bradley David Griffiths, 18" November 2012. We welcome the Coroner's interest and concern in this case and in ensuring that future deaths are prevented and that any risks to patients including those who transfer out of area are managed safely. Your PFD report raised the following ‘Coroner's Concerns’: “Evidence was heard from [iho was Bradley's Health Visitor. || lexplained that she only saw Bradley once, which was for the birth visit on 30" April 2012. Although two appointments were made with Bradley's mum for the 6 week routine check to take place, his mum did not keep them. After the second failed appointment Ms Mackie telephoned Bradley's mum on 26" June 2012 and was informed by her that she had separated from Bradley's father and she and Bradley were living in the Northampton area with friends and that she had registered with a new GP. However, she would not tell here she was living or the details of her new GP. As a resull ent Bradley's records to the “No Trace” storage at the Child Health Department with the expectation that they would be sent to the next assigned Health Visitor.” Your action to be taken details: “In my opinion action should be taken to prevent future deaths and | believe you have the power to take such action.” Page 1 of 2 Jagtar Singh - Chair Simon Gilby - Chief Executive Coventry & Warwickshire Partnership NHS Trust Wayside House, Wilsons Lane, Coventry, CV6 6NY Tel: 024 7636 2100 Fax: 024 7636 8949 www.covwarkpt.nhs.uk ems in partnership with: . }Counly Counc ‘mor UL. fempLover The Trust would like to confirm the following: At the time of Bradley's death, our processes for the Transfer Out of case notes and information, did not robustly account for instances where families did not provide a forwarding GP address, or where they provided incorrect details. Following the incident of Bradley's death in 2012, the Trust had recognised the concerns that you have raised following the inquest in your PFD report. We can confirm that we had taken steps to develop and then implement robust arrangements for ensuring children’s ‘Transferred Out of Area’ records and arrangements for ensuring appropriate levels of contact with receiving areas, are carefully considered; and in circumstances where staff are unable to locate a child/family. The arrangements that we had already proactively put into place were: * Completing a ‘No Trace’ process/checklist, and a follow up review after 3 months; « Supervision of each case, by a Pre-School Manager, to ensure all avenues have been considered, prior to ‘No Trace’ status being applied. The arrangements described above were later incorporated into the Health Visiting Standards document (August 2014). We have kept these arrangements under review, as part of normal process, to ascertain whether any additional improvements can be made to strengthen the process in place. | am sorry that there was not the opportunity to confirm the changes in practice that we had made following Bradley's death. | hope this provides you with the assurance that you require that the Trust did recognise that there was a gap in its service provision and had taken steps to rectify this at the earliest opportunity, shortly after Bradley's death, thereby preventing a recurrence with other patients under our care. Yours sincerely , ! Simon Gilby Chief Executive Coventry and Warwickshire Partnership NHS Trust Page 2 of 2 Jagtar Singh - Chair Simon Gilby - Chief Executive Coventry & Warwickshire Partnership NHS Trust Wayside House, Wilsons Lane, Coventry, CV6 6NY Tel: 024 7636 2100 Fax: 024 7636 8949 www.covwarkpL.nhs.uk ‘MINOFUL Warwickshire yarns be We in partnership with: [Coury Counc
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