Prevention of Future Deaths reports · 2016
Regulation 28 report to prevent future deaths, reference 2016-0083, written 2 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 | 2 Mar 2016 |
|---|---|
| Reference | 2016-0083 |
| Deceased | Curt Falk |
| Coroner | R Brittain |
| Coroner area | Inner North London |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
REGULATION 28: REPORT TO PREVENT FUTURE DEATHS REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: (1) Vaccination and Immunisation, ℅ , London. 79 Whitehall Joint Committee on , Chair HPV Subcommittee Department of Health, Richmond House, 1 CORONER I am R Brittain, Assistant Coroner for Inner North London 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 Curt Falk died on 6 July 2015, aged 65 years old, from acute myeloid leukaemia. An inquest into his death was partheard on 22 January 2016 and concluded on 26 February 2016, at which I recorded a narrative conclusion (see attached). 4 CIRCUMSTANCES OF THE DEATH Mr Falk was diagnosed in early 2015 with squamous cell carcimona (SCC) of the tongue (resulting from Human Papilloma Virus strain 16) and a blood disorder which was categorised variably as ‘high risk myelodysplasia’ (MDS) and ‘acute myeloid leukaemia’ (AML). He underwent curative radiotherapy for the SCC; however, this treatment plan meant that the MDS/AML was not treatable prior to his death. 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) The SCC from which Mr Falk suffered resulted from a viral infection, which is now potentially preventable through vaccination. This issue did not form part of the evidence heard at the inquest because it was not directly relevant to Mr Falk’s death. However, I am concerned that current vaccination policy does not include the vaccination of males against this virus. As such, there is a risk that future deaths could occur in men from the consequences of this infection. 1 6 ACTION COULD BE TAKEN In my opinion action could be taken to prevent future deaths and I believe that the addressee, has the power potentially to take such action. I am aware of the complexities if involved in the institution of mass vaccination campaigns and would be grateful information could be provided regarding the current and potential future scope for vaccinating the population as a whole against this virus. 7 YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 27 April 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. 8 COPIES and PUBLICATION I have sent a copy of my report to the Chief Coroner; Mr Falk’s family; Consultant Haematologist; University Hospital. Consultant Oncologist and Harley Street at 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 2 March 2016 Assistant Coroner R Brittain 2
1 response published against this report on judiciary.uk. A response is a body's written reply to the coroner's concerns; publication is at the discretion of the Chief Coroner's office, so an absent response does not mean nobody replied.
Richard Brittain Assistant Coroner, PA to Senior Coroner St Pancras Coroners Court, Camley Street, London, N1C 4PP. 19 April 2016 Re: Curt Falk (died: 06.07.2015) Regulation 28: Report to Prevent Future Deaths Dear Mr Britten, The Joint Committee on Vaccination and Immunisation (JCVI) is an independent Departmental Expert Committee and a statutory body, constituted for the purpose of advising the Secretary of State on the provision of vaccination and immunisation services. JCVI’s advice and recommendations are based on consideration of scientific evidence from different sources including clinical trials epidemiological reports and impact and cost-effectiveness studies. In order to form a recommendation for a new national programme or changes to an existing national programme the Committee must ensure that this represents the best use of NHS resources by demonstrating cost-effectiveness. The aim of the UK’s current HPV vaccination programme is to prevent HPV related cervical cancers. The programme was introduced in 2008 following the advice of the JCVI which carried out a detailed review of evidence surrounding HPV vaccination including the cost effectiveness of routine and catch-up programmes. At that time JCVI did not recommend vaccination of boys because the evidence indicated vaccinating boys was unlikely to be cost-effective, as vaccine efficacy was high, and high coverage in girls would provide herd protection for boys, meaning that a programme which included boys would provide little additional benefit. The coverage of the HPV programme is high. In the last three years, coverage of the routine programme for the full three-dose course has been consistently above 86%. JCVI keeps the eligibility criteria of all vaccination programmes under review. In October 2013 JCVI recommended a HPV sub-committee be formed to consider a number of issues including vaccinating men who have sex with men (MSM) and the potential extension of the programme to include adolescent boys, because of new and emerging evidence on the association of HPV vaccine types with non-cervical cancers. JCVI subsequently requested that modelling be undertaken by Public Health England (PHE) to re-examine the impact and cost-effectiveness of extending the HPV vaccination programme to adolescent boys. It is anticipated that PHE will submit the work on the cost-effectiveness of extending the HPV vaccination programme to adolescent boys to JCVI by early 2017. Modeling work on vaccinating MSM was already underway as this was considered a priority because this is a group that receives very little indirect benefit from the girls programme. In November 2015 JCVI issued a statement advising that a targeted HPV vaccination programme for MSM aged up to 45 who attend GUM and HIV clinics should be undertaken subject to procurement of the vaccine and delivery of the programme at a cost-effective price. For more information I recommend you access the JCVI webpage which has the latest minutes and statements from JCVI meetings. I have attached the JCVI code of practice which gives details about the Committee and provided links below to the relevant JCVI documents concerning the subject of HPV vaccination. JCVI web page: https://www.gov.uk/government/groups/joint-committee-on- vaccination-and-immunisation#terms-of-reference JCVI 2008 statement on HPV vaccines to protect against cervical cancer: http://webarchive.nationalarchives.gov.uk/20120907090205/http://www.dh.gov.uk/pr od_consum_dh/groups/dh_digitalassets/@dh/@ab/documents/digitalasset/dh_0947 39.pdf Minutes of the JCVI HPV Subcommittee: https://app.box.com/s/600veu6zr6s3gjvx8mkt JCVI statement on HPV vaccination of men who have sex with men: https://www.gov.uk/government/publications/jcvi-statement-on-hpv-vaccination-of- men-who-have-sex-with-men Kind regards Scientific Secretariat to the Joint Committee on Vaccination and Immunisation Public Health England, Wellington House, 133-155 Waterloo Road London SE1 8UG Email: jcvi@phe.gov.uk Chair of JCVI HPV Subcommittee
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