Prevention of Future Deaths reports · 2016
Regulation 28 report to prevent future deaths, reference 2016-0375, written 24 Oct 2016. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 24 Oct 2016 |
|---|---|
| Reference | 2016-0375 |
| Deceased | Hunter Macmillan |
| Coroner | Chinyere Inyama |
| Coroner area | West London |
| 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: CHIEF EXECUTIVE AT THE CHELSEA AND WESTMINSTER HOSPITALS NHS | FOUNDATION TRUST 1 | CORONER 1 am Chinyere Inyama, senior coroner for the coroner area of West 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 On 20'" of November 2015 | commenced an investigation into the death of Hunter Jack Macmillan. The investigation concluded at the end of the inquest on 5" September 2016 with a narrative. 4 | CIRCUMSTANCES OF THE DEATH Hunter Jack Macmillan was booked into the Urgent Care Centre at West Middlesex Hospital before, as a result of his condition, being taken to the Emergency Department at West Middlesex Hospital. He was not triaged in the Emergency Department for over 45 minutes by which time his condition had deteriorated. 6 | ACTION SHOULD BE TAKEN | 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. — Staffing levels in the Emergency Department were not sufficient to be able to follow national (currently NICE Guideline, Sepsis:recognition, diagnosis and early management) or any local policy on treating suspected sepsis. In my opinion action should be taken to prevent future deaths and | believe you and your organisation 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 16” December 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 mn of my report to the Chief Coroner and to the following persons: mz and the parents of Hunter Jack Macmillan. | 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. 9 24™ October 2016 SIGNED BY CORONER Crryama
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