Prevention of Future Deaths reports · 2016
Regulation 28 report to prevent future deaths, reference 2016-0259, written 19 Jul 2016. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 19 Jul 2016 |
|---|---|
| Reference | 2016-0259 |
| Deceased | Rosemarie Dees |
| Coroner | Henrietta Hills QC |
| Coroner area | London Inner (South) |
| Category | Product related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | none published |
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:
The Resuscitation Council (UK)
5th Floor
Tavistock House North
Tavistock Square
London
WC1H 9HR
1
CORONER
I am HENRIETTA HILL QC, Assistant Coroner, for the coroner area of Inner South
District of Greater 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
ROSEMARIE DEES, then aged 57 years, died on 18 April 2016. An investigation into
her death was opened and an inquest held on 19 July 2016.
The inquest heard that Ms Dees had choked on a boiled sweet.
The medical cause of Ms Dees’ death was asphyxia caused by a food bolus in the
larynx.
The conclusion of the inquest was one of accident.
4
CIRCUMSTANCES OF THE DEATH
The circumstances of the death are as follows:
(1) Ms Dees had a range of pre-existing health conditions including COPD. There
was evidence that this led to her often having a dry mouth/throat and coughing
a lot.
(2) Late in the evening of 18 April 2016 she was at home. Her son heard her
banging loudly on the floor. He went to her and found her apparently choking
on something. She lost consciousness. Her son began CPR and called the
London Ambulance Service (“LAS”) who attended. The first LAS staff member
arrived on scene at 00.03 am.
(3) One of the LAS Paramedics used a Supra-Glottic Airway (“SGA”) (an I-Gel) to
manage Ms Dees’ airway.
(4) An Advanced Paramedic (“AP”) arrived and found that the SGA was ineffective,
so she removed it. Upon removing the SGA the AP noticed a red, sticky, sweet-
like substance stuck to the anterior aspect of it.
(5) A further SGA was inserted followed by an Endo-Tracheal Tube using a video
laryngoscope.
(6) Advanced life support continued for 50 minutes.
(7) Ms Dees’ life was pronounced extinct at 01.14 am.
CORONER’S CONCERNS
During the course of the inquest the evidence revealed matters giving rise to concern. In
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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 that the use of an SGA may be inhibited by an
undetected foreign body airway obstruction. Such an obstruction might be spotted if the
use of an SGA was made conditional on the carrying out of a laryngoscopy which it is
understood will soon be LAS protocol.
6
ACTION SHOULD BE TAKEN
In my opinion action should be taken to prevent future deaths and I believe your
organisation has 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 by 14 September 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 and to the following Interested
Persons: the family of Ms Dees and LAS.
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.
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Signed .......Henrietta Hill QC...........................................
Assistant Coroner
2
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