Prevention of Future Deaths reports · 2015
Regulation 28 report to prevent future deaths, reference 2015-0427, written 6 Nov 2015. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 6 Nov 2015 |
|---|---|
| Reference | 2015-0427 |
| Deceased | Brian Shillinglaw |
| Coroner | Veronica Hamilton-Deeley |
| Coroner area | Brighton and Hove |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| Organisation named | Brighton and Sussex University Hospitals NHS Trust |
| 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.
VERONICA HAMILTON-DEELEY, LL.B. Her Majesty’s Senior Coroner for the City of Brighton & Hove THE CORONER’S OFFICE WOODVALE, LEWES ROAD BRIGHTON BN2 3QB Assistant Coroners Telephone: | CATHARINE PALMER LL.B (HONS) Fax: Brighton MICHAEL KEEN KAREN HENDERSON, BSC,BM,MRCPI,FRCA GILVA D.J.TISSHAW, BA(LA W)HONS CORONERS SOCIETY OF ENGLAND AND WALES ANNEX A REGULATION 28: REPORT TO PREVENT FUTURE DEATHS (1) NOTE: This form is to be used after an inquest. THIS REPORT IS BEING SENT TO: 1. Sussex Partnership FoundationTrust, Chief Executive, Mr C Donaghy 1 CORONER am Veronica HAMILTON-DEELEY, Senior Coroner, for the City of Brighton and Hove 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 3% July 2015 | commenced an investigation into the death of Mr Brian James SHILLINGLAW. The investigation concluded at the end of the inquest on 26" — 30" October 2015.The Conclusion of the inquest was a Narrative Conclusion, as per the | attached sheet. 4 CIRCUMSTANCES OF THE DEATH See Record of Inquest 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. VERONICA HAMILTON-DEELEY, LL.B. Her Majesty’s Senior Coroner for the City of Brighton & Hove THE CORONER'S OFFICE WOODVALE, LEWES ROAD BRIGHTON BN2 3QB Assistant Coroners Telephone: Brighton CATHARINE PALMER LL.B (HONS) Fax: Brighton MICHAEL KEEN KAREN HENDERSON, BSC,BM,MRCPI,FRCA GILVA D.J.TISSHAW, BA(LA W)HONS The MATTERS OF CONCERN are as follows. — (1) The creation of Care Plan, Risk Assessment and other admission documentation (2) The amending and updating of these plans, particularly the Risk Assessment by the relevant members of clinical and nursing staff (3) A discussion about the role of the primary nurse and care coordinator which particular reference to ensuring ongoing communication between the various members of the multi-disciplinary team who will look after a patient like Mr Shillinglaw (4) Complying with the Trusts own policies with regard to Risk Assessment and Management which was clearly extremely poorly understood in Mr Shillinglaw’s case. (5) The use of dynamic Risk Assessment, the importance of clearly updating Risk Assessment documentation (6) Understanding the necessity of implementing the Trust's Observation Policy as part of the Risk Assessment and Management process. Ensuring that the Patient's status is recognised and recording it correctly in all paperwork. (7) The knowledge that a Patient is the subject of a Deprivation of Liberty Safeguarding Order, understanding the significance of that and recording that in the paperwork in the Trust’s own premises and ensuring that notification of Status travels with the Patient should he or she need to be admitted to the Acute | Hospital Trust. 6 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. 7 YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this Teport, namely by 28th January 2016 |, 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 | have sent a copy of my report to the Chief Coroner and to the following Interested Persons VERONICA HAMILTON-DEELEY, LL.B. Her Majesty’s Senior Coroner for the City of Brighton & Hove THE CORONER’S OFFICE WOODVALE, LEWES ROAD BRIGHTON BN2 3QB Assistant Coroners Telephone: Brighton, CATHARINE PALMER LL.B (HONS) Fax: Brighton| MICHAEL KEEN KAREN HENDERSON, BSC,BM,MRCPI,FRCA GILVA D.J.TISSHAW, BA(LA W)HONS = aw — Brighton and Sussex University Hospitals NHS Trust Clinical Commissioning Group Care Quality Commission Secretary of State for Health, Department of Health Simon Stevens — Chief Executive NHS England National Patient Safety Agency ONOARWN | am also under a duty to send the Chief Coroner a copy of your response. The Chief Coroner may publish either or both ina 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. i Date: a ji SIGNED BY: Lollasic. Brighton and Heve
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