Prevention of Future Deaths reports · 2016
Regulation 28 report to prevent future deaths, reference 2016-0390, written 31 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 | 31 Oct 2016 |
|---|---|
| Reference | 2016-0390 |
| Deceased | James Flynn |
| Coroner | Thomas Osborne |
| Coroner area | Milton Keynes |
| Category | Hospital Death (Clinical Procedures and medical management) 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.
Thomas Ralph Osborne
Senior Coroner for Milton Keynes
REGULATION 28 REPORT TO PREVENT FUTURE DEATHS
THIS REPORT IS BEING SENT TO: Chief Executive Officer Oxford University Hospitals,
1
CORONER
I am Thomas Ralph Osborne, Senior Coroner for Milton Keynes
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.
http://www.legislation.gov.uk/ukpga/2009/25/schedule/5/paragraph/7
http://www.legislation.gov.uk/uksi/2013/1629/part/7/made
3
INVESTIGATION and INQUEST
On 14th December 2015 I commenced an investigation into the death of James Francis Flynn,
68. The investigation concluded at the end of the inquest on 25th October 2016. The conclusion
of the inquest was a narrative conclusion as attached.
4
CIRCUMSTANCES OF THE DEATH
The deceased suffered from Chronic Pancreatitis. He was last seen by his GP on 12th
November 2015 with acute pancreatitis and was admitted to Milton Keynes Hospital. Mr Flynn
was later referred on to the John Radcliffe Hospital where he was treated. He was discharged
home on the 8th December 2015 arriving at 2058 in the evening.
At 1715 on 9th December his family attended but could not gain access to the house, they went
to the rear of the property and saw Mr Flynn knelt face down on the floor of his ground floor
bedroom. The police forced entry and Mr Flynn was found unresponsive; CPR was commenced
until the paramedic confirmed death at 1806.
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. –
(1) That an elderly patient who was still very unwell was discharged home very late in the
evening without a detailed care plan being in place, His immediate family were unaware of the
discharge and there was no food or provision for him in the house despite being a type 2
diabetic.
(2) Inadequate planning and management of patient discharge will put patients lives at risk.
HM Coroners Office, Civic Offices, 1 Saxon Gate East, Central Milton Keynes, MK9 3EJ
Tel 01908 254326 | Fax 01908 253636
6
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.
7
YOUR RESPONSE
You are under a duty to respond to this report within 56 days of the date of this report, namely by
26th 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.
8
COPIES and PUBLICATION
I have sent a copy of my report to the Chief Coroner and to the following Interested Persons
namely
find it useful or of interest.
, his son. I have also sent it to
the GP and to the CQC who may
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.
9
Dated 31st October 2016
Signature_________________________
Senior Coroner for Milton Keynes
HM Coroners Office, Civic Offices, 1 Saxon Gate East, Central Milton Keynes, MK9 3EJ
Tel 01908 254326 | Fax 01908 253636
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