Prevention of Future Deaths reports · 2016
Regulation 28 report to prevent future deaths, reference 2016-0233, written 20 Jun 2016. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 20 Jun 2016 |
|---|---|
| Reference | 2016-0233 |
| Deceased | Stephanie Marks |
| Coroner | S Fox QC |
| Coroner area | Avon |
| 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. Clevedon Medical Centre Old Street Clevedon BS21 6DG 1 | CORONER lam Dr. S. Fox, QC, Assistant Coroner, for the area of Avon 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 11" August 2015 an investigation commenced into the death of Stephanie Louise Augusta MARKS, Aged 18. The investigation concluded at the end of the inquest on 20" June 2016. The conclusion was that the medical cause of death was la Sudden cardiac death in a setting of anorexia nervosa and hypokalaemia and the conclusion as to the death was a narrative that read: Miss Marks died from the consequences of untreated hypokalaemia. 4 | CIRCUMSTANCES OF THE DEATH Miss Marks died from untreated hypokalaemia which had been reported to the practice on 31.7.15. Systems for passing blood results to GP's at that time were inconsistent. Certain improvements in these have been made since Miss Marks’ 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. — 4. There was no evidence that staff check at 6.30pm each day that all GP messages have been countersigned as received/acted on by the GP's, for that day. 6 | ACTION SHOULD BE TAKEN in my opinion action should be taken to prevent future deaths and | believe you have the power to take such action. 7 YOUR RESPONSE You are under a duty fo respond to this report within 56 days of the date of this report, namely by 16" August 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. COPIES and PUBLICATION | have senta copy of my report to the Chief Coroner and to the following Interested | 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. 20.6.16 (WK VOULEOYE pip Dr. S. Fox, QC
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