Prevention of Future Deaths reports · 2016
Regulation 28 report to prevent future deaths, reference 2016-0013, written 11 Jan 2016. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 11 Jan 2016 |
|---|---|
| Reference | 2016-0013 |
| Deceased | Robin Brett |
| Coroner | Claire Balysz |
| Coroner area | Wiltshire and Swindon |
| 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.
CLAIRE BALYSZ Assistant Coroner for Wiltshire and Swindon REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: Ms Nerissa Vaughan Chief Executive The Great Western Hospital NHS Foundation Trust Marlborough Road Swindon SN3 6BB CORONER lam CLAIRE BALYSZ, Assistant Coroner for Wiltshire and Swindon 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 17/06/2014 | commenced an investigation into the death of Robin Keith Brett, 18. The investigation concluded at the end of the inquest on 22 December 2015. The conclusion of the inquest was Robin died from natural causes contributed to by neglect. CIRCUMSTANCES OF THE DEATH Robin was an 18 year old man who was born with congenital adrenal hyperplasia. This necessitated daily steroid replacement with a need to supplement the daily dose with IV steroids if he became unwell. He was admitted to the Great Western Hospital on 13 June 2014 with history of severe constipation and in an addisonian crisis. This was initially treated appropriately but he was not given the regular steroids that had been prescribed by the doctors. This was an error. When he died at 0430hrs on 14 June 2014 he had not had any steroids since 1200 hrs on 13 June 2014. This significantly weakened his ability to cope with the strain the constipation put on his body. The evidence that | heard at Inquest showed that any patient on long term steroids for whatever reason must not have their steroids stopped suddenly, if they do there is a likelihood of an addisonian crisis and death. 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. — Wiltshire & Swindon Coroner's Office, 26 Endless Street, Salisbury, Wiltshire, SP1 1DP Tel 01722 438900 | Fax 01722 332223 This patient was prescribed steroids appropriately but the nursing staff failed to notice a dose of steroids had been missed. There is no system on the paper drug chart or the electronic prescribing system for alerting medical staff to patients being on long term steroids. ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and | believe you 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 07 March 2016. 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 and to the LOCAL SAFEGUARDING BOARD (where the deceased was under 18) at Swindon Local Safeguarding Children Board, Civic Offices, Euclid Street, Swindon SN1 2JH | have also sent it to Po Regional Medical Director, NHS England South, Bewley House, Marshfield Road, Chippenham, Wiltshire SN15 1JW Mr David Behan CBE, Chief Executive, Care Quality Commission, Citygate, Gallowgate, Newcastle upon Tyne NE1 4PA who may find it useful or of interest. lam 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 11 January 2016 Signature. Clan Bally “ce Assistant Coroner for Wiltshire and Swindon Wiltshire & Swindon Coroner's Office, 26 Endless Street, Salisbury, Wiltshire, SP1 1DP Tel 01722 438900 | Fax 01722 332223
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