Prevention of Future Deaths reports · 2016
Regulation 28 report to prevent future deaths, reference 2016-0191, written 18 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 | 18 May 2016 |
|---|---|
| Reference | 2016-0191 |
| Deceased | Stanley Sampey |
| Coroner | Sean McGovern |
| Coroner area | Warwickshire |
| 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.
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 — George Eliot Hospital
CORONER
lam 5 McGovern, senior coroner, for ihe coroner area of Warwickshire
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 14 March 2016 | commenced an investigation into the death of Stanley SAMPEY 92
years old. The investigation concluded at the end of the inquest on 13 May 2016. The
conclusion of the inquest was accidental death.
CIRCUMSTANCES OF THE DEATH
Mr Sampey was an in-patient at George Eliot Hospital.
While eating a meal in bed on 5 March 2016 he choked on a food bolus.
While medica! staff were dealing with this incident they attempted to suction Mr
Sampey’s airway.
The wall mounted suction device was found not be working and when the crash trolley
containing a portable suction unit arrived it was also not working,
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. There was no working available suction equipment on the Ward to manage the
patient's airway at the time of the cardiac arrest.
2. There was a lack of any structured checking procedure in place to ensure
working suction equipment on wards.
3. The battery on the portable suction unit was found to be flat and the checking
procedure was incorrect.
ACTION SHOULD BE TAKEN
In my opinion action should be taken to prevent future deaths and | believe you as Chief
Executive of the Trust have the power fo 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 13" July 2016. J, the coroner, may extand 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 {a) a ea of Mr Sampey
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.
48" May 2016
Senicr Coroner S McGovern § I We A ews
i)
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