Prevention of Future Deaths reports · 2015
Regulation 28 report to prevent future deaths, reference 2015-0201, written 27 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 | 27 May 2015 |
|---|---|
| Reference | 2015-0201 |
| Deceased | Oliver Asante-Yeboah |
| Coroner | R Brittain |
| Coroner area | Inner North London |
| Category | Child Death (from 2015) |
| Source | judiciary.uk record · original PDF |
| Responses published | 2 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
REGULATION 28: REPORT TO PREVENT FUTURE DEATHS REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: (1) David Behan, Chief Executive, Care Quality Commission (CQC) CQCInquestsandCoroners1@cqc.org.uk 1 CORONER I am R Brittain, Assistant Coroner for Inner North London 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 INVESTIGATION and INQUEST Oliver AsanteYeboah died on 2 November 2014, aged three weeks. The medical cause of death was E. coli sepsis, resulting from mild renal abnormalities and a urinary tract infection. His death was contributed to by a nontherapeutic circumcision which had been performed a few days days prior. An inquest into his death was opened on 7 January 2015 and heard on 15 May 2015, at which I recorded a narrative conclusion (see attached). 4 CIRCUMSTANCES OF THE DEATH Oliver was born on 9 October 2014. His parents identified a Rabbi who agreed to perform a nontherapeutic circumcision. The Rabbi gave evidence at the inquest that he had been certified to perform the procedure by the ‘Initiation Society of Great Britain’ (the organisation which supervises the training of Rabbis to perform circumcisions) and that he has performed two to three circumcisions per week over the past 15 years, without any complications to his knowledge. He set out that his sterilisation procedures include the use of an autoclave (to prepare the necessary surgical instruments) and the application of ‘Dettol’ to the surgical site. The Rabbi noted his consenting procedure comprised discussion of the risk of infection through use of that term only, without further clarification of what infections could develop following the procedure. I heard evidence that the risk of urinary tract infections is increased after circumcision and that this risk is heightened where the procedure is undertaken in a ‘nonmedical’ setting. On 2 November Oliver’s parents took him to their local Emergency Department because he was feeding less well and his sleep pattern had altered. Analysis of his urine demonstrated the presence of an infection. Despite the institution of intravenous antibiotics and attempts to resuscitate him, he rapidly deteriorated and died later on 2 November 2015. 5 CORONER’S CONCERNS During the course of the inquest the evidence revealed matters giving rise to concern. In 1 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) The Rabbi who performed Oliver’s circumcision gave evidence that his practice was not regulated by any official body or organisation. The pathologist who performed the post mortem was clear that she considered the circumcision to be a surgical procedure. The consultant paediatrician, who was involved in attempts to resuscitate Oliver, stated that research has demonstrated an increased risk of infection after circumcision in a nonmedical setting. It was clear from the evidence adduced at the inquest that the circumcision had contributed to Oliver’s death, although it was not possible to conclude that the fact it was performed in a nonmedical setting increased the risk of infection in this particular case. I am concerned that future deaths could occur in similar circumstances, owing to the lack of formal regulation of nonmedical providers of circumcision. 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe that the addressee, has the power to take such action. 7 YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 22 July 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, Oliver’s family, the NHS Trust and the Rabbi who performed Oliver’s circumcision. 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 27 May 2015 Assistant Coroner R Brittain 2
2 responses 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.
16th July 2015 Dear HM Assistant Coroner Britain Inquest into the death of Oliver Asante-Yeboah We write in response to the Regulation 28 report addressed to and received by the Care Quality Commission on 29th May 2015. The report concerns the very sad death of Oliver Asante-Yeboah following a non-therapeutic circumcision performed by Mr who we understand, from your report, was certified to perform the procedure by the ‘Initiation Society of Great Britain’ (an organisation which supervises the training of Rabbis to perform circumcisions). We understand that during the course of the inquest you heard evidence that the risk of urinary tract infections is increased after circumcision and that this risk is heightened where the procedure is undertaken in a ‘nonmedical’ setting. In this case on 2 November 2014 Oliver’s parents took him to their local Emergency Department because he was feeding less well and his sleep pattern had altered. Analysis of his urine demonstrated the presence of an infection. Despite the institution of intravenous antibiotics and attempts to resuscitate him, he rapidly deteriorated and died later on 2 November 2014. In your Regulation 28 report you have expressed concern that non-therapeutic circumcisions (surgical procedures) performed in a non-medical setting are not independently regulated by any official body or organisation. You have asked the Care Quality Commission to respond the these concerns in writing. CQC Response to Regulation 28 report – inquest into the death of Oliver Asante - Yeboah The Care Quality Commission is a statutory body and thus its functions, powers and regulatory remit are determined by statute and Regulations. Schedule 1 to the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010 and from 1 April 2015 the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 define the “regulated activities” the Commission is empowered to regulate. Circumcision for the purpose of religious observance falls within the definition of “surgical procedures” in paragraph 7 to Schedule 1 (2010 Regulations) and paragraph 6 to Schedule 1 (2014 Regulations). However as paragraphs 7 and 6 each make clear the Commission’s regulatory remit is limited to circumcisions for the purpose of religious observance when carried on by a healthcare professional. Healthcare professional is defined in Regulation 2(1) of the 2010 and 2014 Regulations as being “a person registered as a member of any profession to which section 60(2) of the Health Act 1999 applies”. The Commission therefore has no regulatory remit over non-therapeutic circumcisions performed for the purpose of religious observance where the individual carrying out the surgical procedure is not a healthcare professional. In this case we understand Mr was not a healthcare professional. In order to extend the Commission’s regulatory remit to cover non-healthcare professionals the 2014 Regulations would require amendment. This is not within the Commission’s power and can only be undertaken by the Secretary of State. I hope the above clarifies the Commission’s position but should you require any further information please do not hesitate to contact me. Yours sincerely, Head of Registration - London and South
men om Ben Gu MP c Mf Parliamentary Under Secretary of State for Care Quality Department NE HH i NEN ie i II 7 ) of Health POCS 952833 3 OCT 2015 \Tel: 020 7210 4850 Mr R Brittain HM Senior Coroner — Inner North London Poplar Coroners Court 127 Poplar High Street London E14 0AE 2 A October 2015 Thank you for your letter about the death of Oliver Asante-Yeboah. POPLAR CORONER'S COURT I was saddened to hear of this case. I would be grateful if you could please pass my condolences to baby Oliver’s family. Your report detailed the circumstances surrounding Oliver’s death and specifically raised the question of legislation regulating non-medical settings. As you are aware, male circumcision, where it is carried out by a healthcare professional, is regulated by the Care Quality Commission (CQC), included under the regulated activity of ‘surgical procedures’. The NHS normally only performs male circumcision where medically indicated. A change in legislation as suggested would require considerable consultation with all interested parties (including the CQC). Clinical Commissioning Groups (CCGs) are responsible for commissioning services to meet the health needs of local communities. In some areas, particularly where they feel children are at risk of unsafe procedures, CCGs can work with local providers and communities to ensure that a safe and affordable service is available. I will be copying this letter to the clinical lead of each CCG in England to highlight this case and reiterate this point. This is a complex issue for CCGs, for the CQC and for the Department. Our advice for parents is to ensure that circumcision, where necessary, is only carried out by a regulated healthcare professional. I hope that this information/is useful. Thank you for bringing the circumstances of Oliver’s death to my 4ttenfion. Or ~ § . BEN GUMMER
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