Prevention of Future Deaths reports · 2015
Regulation 28 report to prevent future deaths, reference 2015-0288, written 21 Jul 2015. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 21 Jul 2015 |
|---|---|
| Reference | 2015-0288 |
| Deceased | Rachel Hollister |
| Coroner | Wendy James |
| Coroner area | Gwent |
| 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 (1) NOTE: This form is to be used after an inquest. REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: Ms Judith Paget Chief Executive, Aneurin Bevan University Health Board, Headquarters, St. Cadoc’s Hospital, Lodge Road, Caerleon, Newport NP18 3XQ 1 | CORONER | am Wendy Ann James, assistant coroner, for the coroner area of Gwent 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 15.04.13 | commenced an investigation into the death of Rachel Hollister (d.o.b. 17.08.81). The investigation concluded at the end of the inquest on 26.06.15. The conclusion of the inquest was Rachel Hollister died from natural causes as a result of a known but rare complication of pregnancy and childbirth. The medical cause of death being:- Amniotic Fluid Embolism 4 | CIRCUMSTANCES OF THE DEATH During the early hours of 13" April 2013 Mrs. Hollister presented unannounced to the Maternity Unit at the Royal Gwent Hospital. Mrs. Hollister gave birth to her daughter, t 2.40 a.m. She suffered a retained placenta and was transferred to theatre for manual removal where she suffered a cardiac arrest and was pronounced dead at 6.25 a.m. 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. Medical staff and porters either did not follow or were unaware of the Health Board’s Protocols 2. The major obstetric haemorrhage protocol does not meet the guidelines published by the Royal College of Obstetricians and Gynecologists 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 15'" September 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 s i ing Interested Persons | 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] 21" July 2015
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