Prevention of Future Deaths reports · 2016
Regulation 28 report to prevent future deaths, reference 2016-0087, written 1 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 | 1 Mar 2016 |
|---|---|
| Reference | 2016-0087 |
| Deceased | Peter Embra |
| Coroner | Sean McGovern |
| Coroner area | Warwickshire |
| Category | Community health care and emergency services 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.
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, Chief Executive —- Warwickshire County Council 1 CORONER lam S McGovern, senior coroner, for the coroner area of Warwickshire 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 27 November 2016 | commenced an investigation into the death of Peter Embra. The investigation concluded at the end of the inquest on 1 March 2016. The conclusion of the inquest was a Narrative Verdict (Copy attached). 4 | CIRCUMSTANCES OF THE DEATH See Narrative Verdict 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 fo report to you. The MATTERS OF CONCERN are as follows, — The local authority failed to act on an urgent referral from a GP. GP) visited Mr Embra at his home on 9 March 2015 and contacted the local authority asking for an urgent assessment. On 16 March he made a written referral to the local authority asking for an urgent assessment preferably that day. There was an approximately 7 week delay before a Social Worker visited Mr Embra. 6 | ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and f believe you as Chief Executive of Warwickshire County Council 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 report, namely by25 Apri! 2046. |, the corener, 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 l have sent a copy of my report to the Chief Coroner and to the following Interested Persons (3) J - orother 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 io me, the coroner, ai the time of your response, about the release or the publication of your response by the Chief Coroner. 1 March 2016 Senior Coroner S McGovern t \ WGoven,
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