Prevention of Future Deaths reports · 2015
Regulation 28 report to prevent future deaths, reference 2015-0179, written 8 May 2015. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 8 May 2015 |
|---|---|
| Reference | 2015-0179 |
| Deceased | Michael Hacker |
| Coroner | Maria Voisin |
| Coroner area | Avon |
| Category | Community health care and emergency services related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | none published |
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:
4. Ken Wenman, Chief Executive
South Western Ambulance Service
1 | CORONER
1am M. E. Voisin, Senior Coroner, for the Area of Avon
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 16" January 2015 | commenced an investigation into the death of Michael
Lawrence HACKER, Aged 66. The investigation concluded at the end of the inquest on
6" May 2015. The conclusion of the inquest was Natural Causes with the medical
cause of death being la) Gangrene of the foot and 1b) Type 2 diabetes mellitus
4 | CIRCUMSTANCES OF THE DEATH
Mr. Hacker was an eccentric man who refused hospital admission to treat his gangrene.
He was assessed as lacking capacity to refuse admission on 19" December but died on
28" December 2014 at his home address before hospital admission
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. P| an Advocacy and Locum Consultant IMCA expressed in
evidence his concerns in relation to the ambulance service in this particular
case. | heard evidence that South West Ambulance Services Trust had attended
Mr. Hacker previously to take him to hospital for treatment of his gangrene and
had not been successful in persuading Mr. Hacker to go with them.
EE 2n'2<'°< HE {07 the South Western Ambulance
Services [rust before and after Mr. Hacker's death to be told that if an
ambulance turned up at the property then there was a protocol in place that
meant that the crew would not use restraint or apply force if Mr. Hacker did not
want to go with them. HR - xpressed concerns as to the Trust's policy
around the Mental Capacity Act.
If Mr. Hacker had been taken to hospital sooner he may or may not have
received treatment depending on a number of factors including his capacity to
make decisions. | did not make any criticism around the ambulance service in
this case however it did raise a concern with me about prevention of future
deaths.
| am therefore writing this report to ask that you consider your training and policy
around the Mental Capacity Act
ACTION SHOULD BE TAKEN
In my opinion action should be taken to prevent future deaths and | believe you and your
organisation 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 Monday 6" July. |, 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 Interested Persons at the
inquest.
lam 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.
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