Prevention of Future Deaths reports · 2015
Regulation 28 report to prevent future deaths, reference 2015-0207, written 1 Jun 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 Jun 2015 |
|---|---|
| Reference | 2015-0207 |
| Deceased | Ronald Smith |
| Coroner | Nadia Persaud |
| Coroner area | East London |
| Category | Hospital Death (Clinical Procedures and medical management) 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 REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: 1. Chief Executive, Matthew Hopkins, Barking, Havering & Redbridge University it NHS Trust. Executive Offices, Queen’s Hospital, Rom Valley Way, Romford, Essex, RM7 0AG. 1 | CORONER | am Nadia Persaud, Senior Coroner for the area of Eastern Area of Greater 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://www. legislation gov.uk/uksi/2013/1629/part/7/made 3 | INVESTIGATION and INQUEST “| On the 7" February 2014, | commenced an investigation into the death of Ronald Alfred Smith. The investigation concluded at the end of the Inquest on the 28" May 2015. The conclusion of the Inquest was a narrative conclusion George's hospital. A plan was eventually agreed for Mr Smith to undergo the procedure when the endoscopy day team arrived. Sadly he passed away Prior to the procedure taking place. A post-mortem examination was Carried out and the cause of death was confirmed to be: 1a; Intestinal infarction 1b; sigmoid volvulus 11; Hypertensive and Ischaemic Heart Disease 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 that there was a failure in this case to access a flexible sigmoidoscope out of hours. This item of surgical equipment was not available to the surgical registrar who Considered that this was the only intervention that may have benefitted the patient. 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 under a duty to respond to this report within 56 days of the date of this report, namely by 27" 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. COPIES and PUBLICATION | have sent a copy of my report to the Chief Coroner and to the following Interested Persons — a... hter) and the Care.Quality Commission. | will also provide a copy of your report to pion eri of Public Health). | am under a duty to send the Chief Coroner a Copy of your response. | will also copy your response to the other persons listed above. 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] 1* June 2015 [SIGNED BY CORONER]
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