Prevention of Future Deaths reports · 2015
Regulation 28 report to prevent future deaths, reference 2015-0420, written 30 Oct 2015. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 30 Oct 2015 |
|---|---|
| Reference | 2015-0420 |
| Deceased | Dennis Stark |
| Coroner | Alan Wilson |
| Coroner area | Blackpool and Fylde |
| 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 (1)
NOTE: This form is to be used after an inquest.
REGULATION 28 REPORT TO PREVENT FUTURE DEATHS
THIS REPORT IS BEING SENT TO:
Newton House [formerly Regency Hospital]
183 Newton Drive
Blackpool
FY3 8NU
1
CORONER
I am Alan Wilson, Senior Coroner, for the area of Blackpool & Fylde
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
On 2015 I opened an investigation into the death of Dennis Peter Stark aged 47 years.
The inquest concluded on 1st October 2015.
The conclusion of the Coroner as to the death was one of Natural Causes.
The medical cause of death was:
1 (a) Hypoxic brain injury
1 (b) Community acquired pneumonia
.
4
CIRCUMSTANCES OF THE DEATH
Dennis Peter Stark suffered from paranoid schizophrenia and was detained at a
rehabilitation unit in accordance with Mental Health legislation. At approximately
0900 hours on 27 May 2014 he was found unresponsive in his bedroom on the
second floor. An ambulance arrived at 0911 hours. An attending paramedic
noted that he did not have a pulse. After three cycles of cardio pulmonary
resuscitation a pulse was recorded at approximately 0932 hours. He was taken
to hospital arriving with a Glasgow Coma score of 3. Despite subsequent
treatment he proceeded to deteriorate. Clinical observations confirmed evidence
of pneumonia which lead to him suffering a loss of oxygen to the brain which
proved fatal.
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. During the course of the Inquest I heard evidence from a Paramedic Reynolds
who had been called to Regency House (now Newton House) which is a
rehabilitation unit that cares for individuals with mental health issues, Mr Stark
having previously been diagnosed as suffering from schizophrenia. He was an
obese gentleman who weighed in excess of 30 stones, and he had been found
unresponsive in his room. He was residing in a second floor room at the
premises. The premises have no lift. The Paramedic indicated that after her
arrival, there followed a period of time during which Mr Stark had no pulse and
required Cardio Pulmonary Resuscitation. However, once a pulse was noted it
then took the ambulance crew approximately twenty-two minutes to leave the
scene. She clearly felt that the time it took the crew to leave the premises was
contributed to by the absence of a lift in the premises and to the extent that she
felt at least half of the amount of time it took to leave the scene could have been
avoided had a lift been in place. In reality Mr Stark had to be transported with
some difficulty from his room, down some steps, and out to the ambulance and
then taken to hospital. It could not be established from the evidence whether
that increased amount of time contributed to Mr Stark’s eventual demise but I
am concerned that a risk of future deaths may arise should someone requiring
urgent medical attention be accommodated on the second floor of Newton
House whose physical status is such that safe removal of that person from the
building may be compromised and leave paramedics in similar difficulties.
Although evidence was provided by the Nursing staff that when this gentleman
was mobile he was able to use steps at the premises to get around, it appeared
to me that there had been insufficient thought given to the prospect of him
requiring urgent medical attention and whether his size may hinder his removal,
particularly in the event of an emergency.
At the conclusion of the inquest, I indicated to the Properly Interested Persons that I
proposed to write to the Trust by way of a report in accordance with the provisions of
paragraph 7 of Schedule 5 of the Coroners and Justice Act 2009.
6
ACTION SHOULD BE TAKEN
In my opinion action should be taken to prevent future deaths and I believe you
[AND/OR your organisation] have 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 24TH December 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 and to the following Interested
Persons
The family of Dennis Peter Stark
The Coroners Society of England & Wales
The Chief Coroner of England & Wales
Care Quality Commission
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
A.A. Wilson
Alan Wilson
Senior Coroner for Blackpool & The Fylde
Dated: 30th October 2015
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