Prevention of Future Deaths reports · 2015
Regulation 28 report to prevent future deaths, reference 2015-0311, written 7 Aug 2015. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 7 Aug 2015 |
|---|---|
| Reference | 2015-0311 |
| Deceased | Gordon Atkinson |
| Coroner | Ian Arrow |
| Coroner area | Plymouth, Torbay and South Devon |
| Category | Other 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.
IAN MICHAEL ARROW Senior Coroner for Plymouth, Torbay and South Devon REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: Plymouth City Council CORONER lam IAN MICHAEL ARROW, Senior Coroner for Plymouth, Torbay and South Devon 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/ukpga/2009/25/schedule/5/paragraph/7 http://www. legislation.gov.uk/uksi/2013/1629/part/7/made INVESTIGATION and INQUEST On 18/02/2015 | commenced an investigation into the death of Gordon Eric Atkinson, 80 . The investigation concluded at the end of the inquest on 07 August 2015. The conclusion of the inquest was NATURAL CAUSES AGGRAVATED BY SELF-NEGLECT The deceased died in Derriford Hospital, Plymouth on 6 February 2015. He had an unwitnessed fall against an oil filled fire towards the end of 2014 which resulted in burns. He had numerous falls, he had mental capacity, he neglected himself in his own accommodation. His medical cause of death was 1 (a) Bronchopneumonia and Coronary Artery Disease II Infected Chest and Leg Wounds CIRCUMSTANCES OF THE DEATH The deceased was divorced gentleman who lived alone in a Caravan at 19 Valley Walk, Glenholt, Plymouth. He had lived there since the 1970's following a divorce. The caravan was in poor condition, damp and had no running hot water. The deceased spent the majority of his time in his living room where he slept and ate mainly in his chair. He had twice weekly visits from the District Nurse Team. It appears that South Western Ambulance Service called on seven occasions at his address following falls. On 9 January he was admitted to a Care Home and then to a Nursing Home. He was admitted to Hospital where a safeguarding concern was raised. The matter was investigated byl of Devon and Cornwall Police Public Protection Unit. She will be making a Report to Plymouth Adult Safeguarding Board. 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. — [BRIEF SUMMARY OF MATTERS OF CONCERN] (1) The deceased appeared to be living in accommodation that was unsuitable. (2) On the evidence it was clear that the deceased was neglecting himself. In particular, his sister pointed out that his bed was soiled with faeces and remained unchanged. (3) It appeared from the evidence at the Inquest that his care package was inappropriate 3 The Crescent, Plymouth, PL1 3AB Tel 01752 204 636 | Fax 01752 313297 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe that Plymouth City Council have the power to take such action. | would ask please that the provision of care packages to vulnerable individuals who live alone, particularly in accommodation of the type occupied by the deceased (ie caravans without hot water) should be reviewed. | understand will be drawing the matter to the attention of the Adult Safeguarding Board of which Plymouth City Council is a member. YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 02 October 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 | have sent a copy of my report to the Chief Coroner and to the following Interested Persons | his children and sister | 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. Dated 07 August 2015 Signature Senior Coroner for Plyr§6uth, Torbay and South Devon 3 The Crescent, Plymouth, PL1 3AB Tel 01752 204 636 | Fax 01752 313297
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