Prevention of Future Deaths reports · 2015
Regulation 28 report to prevent future deaths, reference 2015-0132, written 1 Apr 2015. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 1 Apr 2015 |
|---|---|
| Reference | 2015-0132 |
| Deceased | John Lowe |
| Coroner | Stephanie Haskey |
| Coroner area | Nottinghamshire |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| Organisation named | Nottinghamshire Healthcare NHS Foundation Trust · Nottingham University Hospitals NHS Trust |
| Source | judiciary.uk record · original PDF |
| Responses published | none published |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
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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. Nottinghamshire Healthcare NHS Trust (hereafter referred to as “the
Trust”)
1
CORONER
I am Miss Stephanie Haskey, Assistant Coroner, for the Coroner area of
Nottinghamshire
2
CORONER’S LEGAL POWERS
I 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
4
5
INVESTIGATION and INQUEST
The death of John Lowe was subject to an Inquest from 23rd to 25th March 2015.
CIRCUMSTANCES OF THE DEATH
John Lowe was an inpatient in wards controlled by the Trust for mental health
assessment and care following his suffering a stroke on 7th January 2014. He had been
transferred to the Trust from medical wards controlled by Nottingham University NHS
Trust, where he had been assessed as being at high risk of falls and had been provided
with 1:1 nursing as a result of such assessment. Whist on mental health wards in the
care of the Trust he suffered a series of falls, the final one of which, on 18th February
2014, caused him to sustain a fractured left neck of femur. This injury made a material
contribution to his eventual death from bronchopneumonia on 26th February 2014.
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 belief amongst members of the Trust’s nursing staff that they
were unable as a matter of policy to provide 1:1 nursing care for a patient in
respect of that patient’s falls risk assessment alone, no matter what that
assessment might be.
2. That there was a belief amongst members of the Trust’s nursing staff that 1:1
nursing could only be provided on the basis of a patient’s particular mental
health needs, and not in respect of his or her physical care needs.
6
ACTION SHOULD BE TAKEN
In my opinion action should be taken to prevent future deaths and I believe your
organisation has the power to take such action.
7
YOUR RESPONSE
1
You are under a duty to respond to this report within 56 days of the date of this report,
namely by 1st June 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.
8
COPIES and PUBLICATION
I have sent a copy of my report to the Chief Coroner and to the following Interested
Persons:
, John Lowe’s granddaughter and
Nottingham University Hospitals NHS Trust,
who may find it useful or of interest.
I 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
1st April 2015 Stephanie Jane Haskey,
Assistant Coroner, Nottinghamshire
2
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