Prevention of Future Deaths reports · 2016
Regulation 28 report to prevent future deaths, reference 2016-0183, written 12 May 2016. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 12 May 2016 |
|---|---|
| Reference | 2016-0183 |
| Deceased | David Aughton |
| Coroner | Michael Singleton |
| Coroner area | Blackburn, Hyndburn and Ribble Valley |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| Organisation named | East Lancashire Healthcare NHS Trust |
| 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) REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: The Chief Executive Officer East Lancashire Healthcare NHS Trust Trust Headquarters The Royal Blackburn Hospital Haslingden Road Blackburn BB2 3HH CORONER Iam Michael Singleton, Senior Coroner for the Coroner area of Blackburn, Hyndburn & Ribble Valley. 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. INVESTIGATION and INQUEST On the 27" of January 2016 I commenced an investigation into the death of David Aughton aged 63 years. The investigation concluded at the end of the Inquest which was concluded on the 11" May 2016. The conclusion of the Inquest was that David Aughton had died from an Accidental Death. CIRCUMSTANCES OF THE DEATH In August 1999 David Aughton fell and sustained a severe traumatic brain injury which led to epileptic seizures. Those seizures were controlled by lamotrigine and sodium valproate. On the 21% December 2015 he was admitted to the Royal Blackburn Hospital for a cystoscopy which was performed under general anaesthetic. Whilst at the Royal Blackburn Hospital he had not been administered his anticonvulsant medication such that on the 224 December 2015 he had a grand mal convulsion which caused aspiration pneumonia. Thereafter he remained unwell until he died on the 25" January 2016. CORONER'S CONCERNS During the course of the Inquest the evidence revealed matters giving arise to concern. In my opinion there is a risk that further deaths will occur unless action is taken. In the circumstances it is my duty to report to you the MATTERS OF CONCERN being as follows: - That despite the fact that his regular medications including lamotrigine and sodium valproate were recorded in his medical records, those medications had not been dispensed, leading to a grand mal convulsion it was apparent that there was no mechanism in place to ensure that essential medications were prescribed, dispensed and administered. ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I 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 7** July 2016. I, the Coroner, may extend this 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 if I have sent a copy of my report to the Chief Coroner and to the following interested person, namely: Tam 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. 12 May 2016 Signed by: mean ee fr forth tee H M Senior Coroner for Blackburn, Hyndburn & Ribble Valley tN
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