Prevention of Future Deaths reports · 2015
Regulation 28 report to prevent future deaths, reference 2015-0462, written 13 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 | 13 Nov 2015 |
|---|---|
| Reference | 2015-0462 |
| Deceased | Irene Scholey |
| Coroner | Melanie Williamson |
| Coroner area | West Yorkshire (East) |
| 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.
ANNEX A
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:
1. Joanne Roney,Chief Executive, Wakefield MDC, County Hall, Bond Street,
Wakefield, WF1 2QW.
2. PE :<202200 Chair of Wakefield District Safeguarding
ults Board, Grange View, Annie Street, Outwood, Wakefield, WF1 2PW.
CORONER
!am Melanie Jane Williamson, assistant coroner, for the coroner area of West Yorkshire
(eastern district}
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 1 INVESTIGATION and INQUEST
On the 15" August 2012 | commenced an investigation into the death of Irene Scholey,
aged 73 years. The investigation concluded at the end of the inquest on the 6!”
November 2015. The conclusion of the inquest was a narrative conclusion (see
attached), and the medical cause of death was'-
1{a) Pneumonia and empyema
4 | CIRCUMSTANCES OF THE DEATH
See attached Narrative Conclusion.
a]
CORONER’S CONCERNS
During the course of the inquest the evidence revealed matiers giving rise to concern. tn
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) Mrs Irene Scholey was an elderly and vulnerable 73 year old lady.
{2} In around 2010 Mrs Scholey commenced residing permanently with two of her
daughters.
(3) The household was dysfunctional, was an inappropriate environment for Irene
Scholey to be living in, and was a risk to her physical and emotional wellbeing.
—
] (4) A safeguarding alert was raised in respect of Mrs Scholey in April/May 2012.
(5) Her wellbeing would have been safeguarded had all relevant agencies been able to
access, and to share, information relating to the home environment in which Mrs
Scholey was living.
(6) The Multi Agency Safeguarding Hub (“MASH”) in Wakefield is a gold standard
service providing agencies with access to/sharing of information concerning
safeguarding issues in respect of children.
(7) MASH could be extended to include the elderly (65 years and above) and vulnerable
adults.
(8) There are many adults in a similar position to that of Irene Scholey in this District for
whom MASH would be of enormous benefit.
6 | ACTION SHOULD BE TAKEN
In my opinion action shouid be taken to prevent future deaths and } believe Wakefield
MDC has 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 8” 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 :-
(1)
(2)
| have also sent my report to the following persons who may find it useful or of interest-
(1) | ES Fieldhead Hospital
(2) lead of Legal Services, Pinderfields Hospital
(3) RE Viv Segerius-Allick, West Yorkshire Police
‘am aiso 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 | 13° November 2015 Minr~
—
MELANIE J WILLIAMSON
Assistant Coroner
West Yorkshire (eastern district)
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