Prevention of Future Deaths reports · 2015
Regulation 28 report to prevent future deaths, reference 2015-0168, written 29 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 | 29 Apr 2015 |
|---|---|
| Reference | 2015-0168 |
| Deceased | Rasharn Williams |
| Coroner | Mary Hassell |
| Coroner area | Inner North London |
| Category | Other related deaths · Child Death (from 2015) |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
Regulation 28: Prevention of Future Deaths report
Rasharn Kirk WILLIAMS (died 23.10.14)
THIS REPORT IS BEING SENT TO:
1.
Headteacher
Berger Primary School
Anderson Road
London E9 6HB
1
CORONER
I am: Coroner ME Hassell
Senior Coroner
Inner North London
St Pancras Coroner’s Court
Camley Street
London N1C 4PP
2
CORONER’S LEGAL POWERS
I make this report under the Coroners and Justice Act 2009,
paragraph 7, Schedule 5, and
The Coroners (Investigations) Regulations 2013,
regulations 28 and 29.
3
INVESTIGATION and INQUEST
On 29 October 2014, one of my assistant coroners, Richard Brittain,
commenced an investigation into the death of Rasharn Williams, aged 9
years.
The investigation concluded at the end of the inquest on 24 April 2015,
when I made a determination that Rasharn died from natural causes.
His medical cause of death was:
1a hypoxia
1b generalised seizure
1c univentricular cyanotic congenital heart disease
with pulmonary hypertension
1
4
CIRCUMSTANCES OF THE DEATH
Rasharn’s cardiologist had not expected him to live to adulthood, but had
not expected him to die this quickly. He was a little boy who enjoyed life
and engaged with it fully, despite his heart problem. Upon the direction of
his doctors and with the agreement of his mother, Rasharn was allowed
to participate in school activities, but then to sit out when he felt tired.
On 23 October 2014, he was having fun at a school disco when he
became fatigued and sat down. He was noticed by a teacher who
approached him. He began to cry and was breathless and distressed, so
she took him into the school office to sit down. This was at approximately
4.30pm. Rasharn’s mother was telephoned and asked to come in to
school.
After a while, Rasharn appeared to improve a little, and the teacher left
him with two members of the administrative staff. One of these was a
permanent member who was also a first aider, and one was a more
junior, temporary member who was not a first aider but, coincidentally,
had looked after a little boy with epilepsy in the past.
Approximately seventeen minutes after being brought in to the office, at
around 4.47pm, Rasharn deteriorated and became somewhat absent.
The junior member of staff suspected him to be having a seizure and
asked if an ambulance should be called. The first aider did not think this
was a seizure and so formed the view that an ambulance should not be
called.
Despite the fact that Rasharn had never suffered a seizure before, and
was not thought to be particularly at risk of seizures, the likelihood is that
this was a seizure from which he never really recovered, and that he later
had more seizure activity.
His mother arrived three minutes after the seizure began, at around
4.50pm. Four minutes after that, at 4.54pm, the first aider called an
ambulance. The ambulance arrived at 5.03pm. While Rasharn was in
the back of the ambulance but still on the premises, at 5.14pm, he
suffered a cardiac arrest. He was treated and transferred to hospital,
arriving at 5.19pm.
Rasharn was treated aggressively in hospital, but died later that evening.
It is unclear whether earlier medical intervention could have changed the
outcome on this particular occasion.
2
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 staff at the school were clear that they should call an
ambulance in the case of an emergency, and I heard evidence
from the first aider that she would have called an ambulance
immediately if she had thought Rasharn was having a seizure,
Rasharn’s care plan was not wholly clear on this point.
The plan described breathlessness as an emergency. I appreciate
that this may have had its origin with Rasharn’s treating clinicians.
However, his exercise tolerance was reducing all the time and so
breathlessness was, to a degree, a feature of his condition.
Extreme breathlessness coupled with low oxygen saturations
would be a different matter, but this was not made clear in the
plan.
This potential lack of clarity did not have an impact on the outcome
in this particular situation, but it might in another. It seems that
your care plans may benefit from some review to ensure that there
is no ambiguity unwittingly created for those attempting to follow
them.
2. I heard that some schools have notices with a child’s photograph
and particular instructions regarding medical conditions, displayed
in the staff room, office and medical room.
Rasharn did have such a notice, but it was only in the medical
room, and was not actually displayed at the time of his death,
transitional arrangements regarding a move of
because of
premises.
Again, this did not have an impact on the outcome for him, but
might for another child.
6
ACTION SHOULD BE TAKEN
In my opinion, action should be taken to prevent future deaths and I
believe that you have the power to take such action.
3
7
YOUR RESPONSE
You are under a duty to respond to this report within 56 days of the date
of this report, namely by 26 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 following.
HHJ Peter Thornton QC, the Chief Coroner of England & Wales
Rasharn’s mother
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
interest. You may make
representations to me, the Senior Coroner, at the time of your response,
about the release or the publication of your response by the Chief
Coroner.
it useful or of
find
9
DATE SIGNED BY SENIOR CORONER
29.04.15
4
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.
MATTER: RASHARN WILLIAMS MATTER NO: 780901 CLIENT CODE: G4597 RESPONSE TO REGULATION 28 PREVENTION OF FUTURE DEATH REPORT FOR RASHARN WILLIAMS (DIED 23 OCTOBER 2014) Response of Mr re S Head Teacher at Berger Primary School, Anderson Road, London E9 6HB. 1 Legal\131$6932.1 HM Coroner raised concerns regarding clarity of emergency situations on the Child Healthcare Plan. We have undertaken a review of all existing care plans and in particular reviewed the emergency provisions. If the emergency is not clear as to what constitutes an emergency for the child and the action to be taken then the appropriate SENCO will refer the matter back to the school nurse and/or the hospital consultant for clarification. The policy for the Education for Children with Medical Needs will be amended to include: if an individual Healthcare Plan is not clear as to what is regarded as an emergency for the child and the action to be taken, the member of staff responsible will clarify these provisions with the school nurse and/or the hospital contact identified on the Healthcare Plan. The school will ensure that all children with severe medical conditions will have their photograph and a summary of their condition and treatment placed in the staff room and the medical room. This will be based upon those children who have to: (a) Use an Epi Pen for their condition; (b) Administer medicine; (c) Epilepsy or seizures; Page 1 of 2 (d) More serious illnesses 4 Healthcare Plans affect 15% of the children thus those who work with a particular child with a Healthcare Plan are made aware of that child’s condition and the treatment required. It would not be possible to exhibit all the children who are subject to a Healthcare Plan on the staff room wall and medical room. 5 In addition children who have food allergies have their pictures in the kitchen so they are not provided with food to which they are intolerant to. 6 These arrangements were in force prior to the transitional arrangements regarding the move of premises and are now in force with additional photographs in the staff room. Dated: Zeloblis sas esannaasacee reece Legat\13156932.1 Page 2 of 2
See every Prevention of Future Deaths report matching Child Death (from 2015), 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.