Prevention of Future Deaths reports · 2016
Regulation 28 report to prevent future deaths, reference 2016-0443, written 12 Dec 2016. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 12 Dec 2016 |
|---|---|
| Reference | 2016-0443 |
| Deceased | Dennis Lavington |
| Coroner | Grahame Short |
| Coroner area | Southampton and New Forest |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| Organisation named | Solent NHS Trust |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
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.
Grahame Antony Short Senior Coroner for Southampton & New Forest REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: Solent NHS Trust CORONER lam Grahame Antony Short, Senior Coroner for Southampton & New Forest 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. http://www. legisiation.gov.uk/ukpga/2009/25/schedule/5/paragraph/7 http:/Avww.legisiation.gov.uk/uksi/2013/1629/part/7/made INVESTIGATION and INQUEST On 05/02/2016 | commenced an investigation into the death of Dennis Thomas Lavington aged 84. The investigation concluded at the end of the inquest on 12 December 2016. The conclusion of the inquest was Road traffic collision CIRCUMSTANCES OF THE DEATH At about 12.45 on 13 January 2016 Dennis Lavington was crossing the car park outside Adelaide Health Centre at Millbrook Southampton using a walking frame when his frame was struck by a Vauxhall Zafira taxi reversing across the car park and he fell to the ground and struck his head, as a result of which he suffered concussion, He was taken to Southampton General Hospital and admitted but later developed pneumonia and died there of Hospital Acquired Pneumonia due to Chronic Kidney Disease, Previous Myocardial Infarction, Type 2 Diabetes Mellitus, Emphysema, Concussion following Road Traffic Collision 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. — The layout of the health centre car park leads to a potential conflict between pedestrians and car drivers. Whilst there is a drop off point outside the entrance, many of the patients are likely to be parking in the disabled parking spaces and they then have to cross the car park to reach the entrance. If there was a dedicated crossing or a marked path around the edge of the car park with improved signage, this would minimise the risk of a similar incident. Coroner's Office, Castle Hill, Fhe Castle, Winchester, S023 8UL Tel 01962-667884 | Fax 01962-667893 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you Solent NHS Trust 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 08 February 2017. |, the coroner, may extend the period. Your response must contain details of action taken or proposed to be taken, setting out the L timetable for action. Otherwise you must explain why no action is proposed. 8 COPIES and PUBLICATION | have sent a a of um ane to the Chief Coroner and to the following Interested Persons: 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. 9 Dated 12 December 2016 Signature € hy wk Senior Coroner for Southampton & New Forest Coroner's Office, Castle Hill, The Castle, Winchester, SO23 8UL Tel 01962-667884 | Fax 01962-667893
1 response published against this report on judiciary.uk. A response is a body's written reply to the coroner's concerns; publication is at the discretion of the Chief Coroner's office, so an absent response does not mean nobody replied.
SOUTH WEST HAMPSHIRE LIFT bullding healthier communities South West Hampshire LIFT Limited 15th Floor, Cobalt Square 83-85 Hagley Road Birmingham B16 80G TEL: 0121 456 5662 PO a 28 FER 20l7 FAX: 0121 452 5619 Coroner’s Office, Castle Hill, The Castle, Winchester, $023 8UL. 27" February 2017 Dear Mr Harris, Re: The late Dennis Thomas LAVINGTON (re:00213-2016) Further to my letter dated 8"" February 2017, please be advised that | am writing to inform you that the Transport Planning Consultancy report regarding the proposed car parking improvement measures at Adelaide Health Centre, Millbrook, Southampton, SO16 4XE has now been reviewed by an independent Health and Safety Adviser appointed by the South West Hampshire LIFT Company Board. The outcome of this review endorses the proposed improvements measures identified in the TPC report, therefore, the Board has instructed such measures to be implemented. Please also note, that it is anticipated planning consent will be required from the local planning authority to implement some of the measures identified and therefore we will seek to progress the improvements at the earliest opportunity. din England and Wales istration number 6437193 Should the Senior Coroner have any queries regarding these matters, then | will be more than happy to discuss them further. Your sincerely ECE Head of Estates and Performance Management. For and on behalf of South West Hampshire LIFT Company
See every Prevention of Future Deaths report matching Solent NHS Trust, and how often a new one appears.
What would an alert for this have sent me? Search the full text
Free to try — the preview shows the real matches and how many arrived in the last 12 months. Your first email alert is free.
These reports are published by the Chief Coroner's office at judiciary.uk and are © Crown copyright. The text here is reproduced from the published PDF so it can be searched. If something on this page is wrong, or you are a person named in it and want it reviewed, email drcjar@gmail.com and we will act promptly.