Prevention of Future Deaths reports · 2015
Regulation 28 report to prevent future deaths, reference 2015-0182, written 11 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 | 11 May 2015 |
|---|---|
| Reference | 2015-0182 |
| Deceased | John Lobo |
| Coroner | Selena Lynch |
| Coroner area | South London |
| Category | Other 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.
In the South London Coroners Court Inquest touching the death of John Lobo REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: Exora Medical Limited, Unit 9 Balmoral Storage, Clive Way, Watford WD24 4PX 1 | CORONER | am Selena Lynch senior coroner for the coroner area of South London 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. http:/Avww .legislation.gov.uk/ukpga/2009/25/contents 3 | INVESTIGATION and INQUEST Ong" July 2014 | commenced an investigation into the death of John Lobo, aged 77 years. The investigation concluded at the end of the inquest on 21" April 2015. The conclusion of the inquest was that his death was accidental. The medical cause of death was 1a Bilateral bronchopneumonia 1b chronic obstructive airways disease Part Il Ischaemic heart disease; cervical spine fracture and diabetes mellitus. 4 | CIRCUMSTANCES OF THE DEATH On 15" May 2014 Mr Lobo suffered a fall in his bathroom on the cruise ship Ventura, close to the Italian coast. He suffered two further falls on the 19" and 21° May 2014 which may have exacerbated the injury. He was then admitted to a hospital in Venice and was subsequently transferred to the United Kingdom in a private ambulance. He was transported by road and his neck was not immobilised at all times during the journey. A dispute with the insurance company meant that the family had to make a private arrangement for repatriation, and although the ambulance company were made aware that Mr Lobo had suffered a fracture at C7 they wrongly recorded that the fracture was at T7. The ambulance crew (which included a paramedic) were informed by the Italian hospital that he was fit to travel and should be immobilised at times of transfer only. There was no indication that the fracture was in fact unstable, which may have been as a result of language difficulties. Translation services were available but not used. The evidence disclosed that transport by road was not appropriate, and that Mr Lobo should have been immobilised at all times, and these failures contributed to the cause of death. 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. — The evidence disclosed that assessment of fitness to travel and of the manner in which the patient should be transported requires medical knowledge over and above that of a paramedic, and that reliance should not be placed wholly on family members and hospitals in distant countries. In cases involving direct repatriation without the facilities provided by an insurance company, consideration might be given to obtaining independent medical assessment. 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 undera duty to respond to this report within 56 days of the date of this report, namely by 6" July 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. (You have already filed a statement to assist this process, but should nevertheless respond fully, whether by re-submitting the statement or otherwise.) COPIES and PUBLICATION | have sent a copy of my report to the Chief Coroner and to the following Interested Persons The family of Mr Lobo | have also sent it to the ae: and to the Care Quality Commission 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. DATE SIGNED BY CORONER 1A Mary 201 S. Quer ody vce
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.
~6 JUL 2015 E YORA MEDICAL In the South London Coroners Court Inquest touching the death of John Lobo Response to Coroner’s Regulation 28 Report Following the Inquest which took place on 21 April 2015, we reviewed the facts of this case against our company policies and presented a written statement which was provided to the Court on 27% April 2015. We now provide below our response to the Coroner’s Regulation 28 Report dated 11 May 2015. Senior Coroner Selena Lynch has suggested that in cases involving direct repatriation of a patient without the facilities provided by an insurance company, consideration might be given to obtaining an independent medical assessment when assessing fitness for travel. We would stress that, in accordance with our company policy, obtaining confirmation of fitness to travel from a competent medical practitioner always has been, and remains, an absolute requirement of Exora Medical Limited when accepting instructions to transfer any patient. In our experience, the medical practitioner who has treated the patient is usually best placed to assess a patient's fitness to travel. Notwithstanding the above, going forward we shall give consideration to obtaining a second and independent medical assessment in situations where facilities are not being provided by an insurance company for repatriation especially in circumstances where the repatriation is taking place from a distant country. Exora Medical Limited ort. us (welv0ys Care Quality ES 4 § cure & Commission 1SO9001 iaa Barring Service Exora Medical Limited| Unit 9, Balmoral Storage, Clive Way, Watford, WD24 4PX | Tel: 0845 47 505 44 | Fax: 0845 47 505 45| www.exoramedical.com | info@exoramedical.com Registered in England & Wales No: 08085826, VAT No. 138 9413 89
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