Prevention of Future Deaths reports · 2016
Regulation 28 report to prevent future deaths, reference 2016-0081, written 3 Mar 2016. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 3 Mar 2016 |
|---|---|
| Reference | 2016-0081 |
| Deceased | Christopher Stubbs |
| Coroner | Martin Fleming |
| Coroner area | West Yorkshire (West) |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths · Suicide (from 2015) |
| Organisation named | Bradford District Care NHS Foundation Trust |
| 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.
IN THE WEST YORKSHIRE WESTERN CORONER’S COURT IN THE MATTER OF: __________________________________________________________ The Inquest Touching the Death of Christopher John Stubbs A Regulation Report – Action to Prevent Future Deaths __________________________________________________________ THIS REPORT IS BEING SENT TO: – Wibsey & Queensbury Medical Practice 1 CORONER Martin Fleming HM Senior Coroner for West Yorkshire Western 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 20 of the Coroners (Investigations) Regulations 2013 3 INVESTIGATION and INQUEST On 30 July 2015 I opened an inquest into the death of Christopher John Stubbs who, at the date of his death, was aged 36 years old. The inquest was resumed and concluded on 20 February 2016 I found that the cause of death to be: ‐ 1a. Hanging I arrived at a conclusion of suicide. 4 CIRCUMSTANCES OF THE DEATH On 26 July 2015 Christopher John Stubbs, who had a history of mental ill health and drug misuse and a previous attempt to take his own life by drug overdose on 7 February 2015, was found suspended from a ligature made from a bath robe cord attached to a door on the landing of his home address. It was found that he intended to take his own life. 5 CORONER’S CONCERNS During the course of the inquest I heard that Christopher’s prescribed medication of mirtazapine and pregabalin was stopped by the acute hospital doctors on his discharge from the hospital following his overdose of 7 February 2015, pending a further review by his GP, which I heard did not take place prior to his death. The MATTER OF CONCERN is as follows. – To review the effectiveness of existing office systems and procedures in relation to the receipt of discharge summaries from hospitals which advise on the review of patient’s medication. 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe that Wibsey & Queensbury Medical Practice has the power to take such action. 7 YOUR RESPONSE You are under a duty to respond to this report within 56 days of its date; I may extend that period on request. Your response must contain details of action taken or proposed to be taken, setting out the timetable for such action. Otherwise you must explain why no action is proposed. 8 COPIES I have sent a copy of this report to: (mother) Bradford District Care NHS Foundation Trust NHS England Chief Coroner 9 DATED this 3rd March 2016 M. D. Fleming Senior Coroner
See every Prevention of Future Deaths report matching Bradford District Care NHS Foundation Trust, and how often a new one appears.
What would an alert for this have sent me? Search the full text
Free to try — the preview shows the real matches and how many arrived in the last 12 months. Your first email alert is free.
These reports are published by the Chief Coroner's office at judiciary.uk and are © Crown copyright. The text here is reproduced from the published PDF so it can be searched. If something on this page is wrong, or you are a person named in it and want it reviewed, email drcjar@gmail.com and we will act promptly.