Prevention of Future Deaths reports · 2015
Regulation 28 report to prevent future deaths, reference 2015-0230, written 17 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 | 17 Jun 2015 |
|---|---|
| Reference | 2015-0230 |
| Deceased | Andrew Nickolls |
| Coroner | Ian Arrow |
| Coroner area | Plymouth, Torbay and South Devon |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | none published |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
REGULATION 28: REPORT TO PREVENT FUTURE DEATHS
This report is made under paragraph 7, Schedule 5, of the
Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners
(Investigations) Regulations 2013
Recipients
This report is being sent to:
Chief Executive, Northern Eastern and Western Devon Clinical
Commissioning Group
Chief Executive, Torbay & South Devon Clinical Commissioning Group
Chief Executive, Plymouth City Council
Chief Executive, Devon County Council
Chief Executive, Torbay Council
Coroner
I am IAN MICHAEL ARROW, Senior Coroner for the area of Plymouth, Torbay &
South Devon
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
Investigation and Inquest
On the 15th October 2013 I commenced an Inquest into the death of Andrew John
Nickolls. The Inquest concluded on the 10th June 2015.
The medical cause of death was found to be:
1a Unascertained
The conclusion of the Inquest was “Open”.
The deceased was found dead and decomposing at Flat 11 Newcomen Court,
Dartmouth. On the balance of probability. The Coroner heard evidence he had been
consuming a significant amounts of alcohol. He had previously had numerous
hospital admissions.
Circumstances of death
The deceased was discharged from Torbay Hospital on the 12th September 2013.
When a cause for concern was raised he was found by Police Officers in his flat.
Coroner’s concerns
During the course of the Inquest I received evidence by way of a detailed report
from
giving rise to concerns. 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 pertinent circumstances of Andrew’s death were that he was living in
Dartmouth. He was registered with a GP in Plymouth. He attended Torbay Hospital
on numerous occasions.
Following his death the Torbay & South Devon Clinical Commissioning Group
conducted an investigation into the circumstances of his death. This investigation
was carried out by
A copy of her report with substantial
recommendations has been shared with the NEW Clinical Commissioning Group
and the Torbay & South Devon Clinical Commissioning Group. I also understand
copies are to be shared with The Chief Executive of: Plymouth City Council, Devon
County Council and Torbay Council.
The principal learning point is to be that there is an advantage in a patient being
looked after by a primary carer (i.e. a GP) within the Clinical Commissioning
Group. If this is not the case, then it is imperative that there is clear information
sharing, particularly where there is a vulnerable adult and there is a possibility they
are neglecting themselves.
May I observe there may be an advantage in sharing information with Devon &
Cornwall Police who clearly keep an index of vulnerable individuals as these
individuals may come to the Forces notice through other routes.
Action should be taken
I would ask you please to consider what steps could be taken to ensure there is
prompt exchange of information about an individual’s personal circumstances and
where appropriate, should they be a vulnerable individual, for them to be provided
support from a Safeguarding Adult team.
Your response
You are under a duty to respond to this report within 56 days of the date of this
report namely, 12th August 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.
Copies and publication
I have sent a copy of my report to The Chief Coroner and to the following interested
persons
The Chief Constable of Devon & Cornwall Constabulary
MP for Totnes and Chair of the Health Select
Committee
Secretary of State for Health
Family members
I am 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 to the Chief
Coroner
I.M. ARROW
Senior Coroner – Plymouth, Torbay & South Devon
Dated 17th June 2015
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