Prevention of Future Deaths reports · 2015
Regulation 28 report to prevent future deaths, reference 2015-0114, written 24 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 | 24 Mar 2015 |
|---|---|
| Reference | 2015-0114 |
| Deceased | Michael Richardson |
| Coroner | David Osborne |
| Coroner area | Norfolk |
| 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 (1) NOTE: This form is to be used after an inquest. REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: The Chief Executive James Paget University Hospital NHS Foundation Trust Lowestoft Road : Gorleston Great Yarmouth NR31 6LA 1 | CORONER lam DAVID OSBORNE, assistant coroner, for the coroner area of Norfolk 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 18 March 2014 | commenced an investigation into the death of Michael Barry Richardson aged 66 years. The investigation concluded at the end of the inquest on 18 March 2015. The conclusion of the inquest was that the medical cause of death was 1a Bronchopneumonia, 1b Pulmonary Fibrosis, 2 Pulmonary hypertension and Ischaemic Heart Disease and that Mr Richardson died from natural causes. 4 | CIRCUMSTANCES OF THE DEATH Mr Richardson was admitted to the James Paget University Hospital on 24 October 2013 following a deterioration in his lung disease. He was diagnosed as suffering from an infective exacerbation of his pulmonary fibrosis and a community acquired pneumonia. ‘Despite treatment he arrested and died on 27 October 2013. On admission a MUST screen was carried out by a student nurse with a score of 0. 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. — There was within Mr Richardson’s records an ambulance crew report which recorded that Mr Richardson was said to have not eaten for 5 days. In evidence before me it was confirmed that the ambulance report would have been available to the person who undertook the MUST screen. [t also appeared that this may not have been reviewed at the time. If it had been reviewed the evidence given before me was to the effect that the information might have led to a MUST score of 2 which would in turn have led to a referral to dietician services. Although the expert evidence was that Mr Richardson's nutrition did not play a material part in his death, | am nevertheless concerned that in different circumstances a failure to follow up information or review the ambulance record and/or any other records with which a patient is admitted and so miss the information could affect the outcome for the patient and that there j is therefore.a risk of future deaths. 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 duly to respond to this report within 56 days of the date of this report, namely by 11 May 2015. 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. COPIES and PUBLICATION | have sent a copy of my report to the Chief Coroner and to the following interested Persons: eS ic) Hs (aughier) | have also sent it to the Department of Health 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. 24 March 2018 David Osborne, Assistant 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.
James Paget University Hospitals INHS NHS Foundation Trust a J APR 2015 Lowestoft Road Gorleston Great Yarmouth . Norfolk 21st April 2015 NR31 6LA Private and Confidential Main Switchboard: 01493 452452 Mr David Osborne Assistant Coroner for Norfolk Direct SC 69 — 75 Thorpe Road Direct Fae Manat ae Norfolk NR1 1UA Dear Mr Osborne RE: Regulation 28 Report to Prevent Future Deaths following the inquest into the death of Michael Richardson Thank you for your report dated 24" March 2015 following your inquest into the death of Mr Michael Barry Richardson. | understand that you have made 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. We have considered the issues you raised with regard to MUST risk assessments to assess nutritional status and we have developed an action plan to address the weaknesses identified. | have attached a copy of this action plan, which includes the actions we have already taken and those we plan to take, including timescales and respons les. This action plan will be monitored by the Trust's Patient Safety and Effectiveness Committee, chaired by the Director of Nursing, Quality and Patient Experience. | would like to thank you for bringing your concerms to my attention. Please do not hesitate to contact me if you require anything further. Yours sincerely Christine Allen Chief Executive CC:
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