Prevention of Future Deaths reports · 2016
Regulation 28 report to prevent future deaths, reference 2016-0496, written 5 Apr 2016. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 5 Apr 2016 |
|---|---|
| Reference | 2016-0496 |
| Deceased | Dorothy Imisson |
| Coroner | James Adeley |
| Coroner area | Preston and West Lancashire |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| Organisation named | Blackpool Teaching Hospitals NHS Foundation Trust |
| 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
THIS REPORT IS BEING SENT TO:
1. Blackpool Teaching Hospitals NHS Trust
CORONER
!am Dr James Adeley, senior coroner/area coroner/assistant coroner, for the coroner
area of Preston and West Lancashire
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 legislation. gov .ul/ukpga/2009/25/schedule/S/paraqraph/7
hito:/www.legislation.gov.uk/uksi/2013/1629/part/7/made
INVESTIGATION and INQUEST
On 29/09/2014 | commenced an investigation into the death of Dorothy Imisson, aged
82. The investigation concluded at the end of the inquest on 05/04/2016. The conclusion
of the inquest was:
Dorothy Imisson died on 9 August 2014 at Cleveleys Nursing Home from a
naturally occurring stroke caused by atrial fibrillation. Dorothy Imisson's death
was contributed to by an absence of pressure care planning by qualified staff
resulting in a premature development of severe skin ulceration, a shortening of
life and increased pain and suffering.
CIRCUMSTANCES OF THE DEATH
The circumstances of the death are fully set out in the attached Summing Up and
Conclusion.
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) No appropriate care plan was developed by the District Nursing Service.
(2) The District Nursing Service are compromising patient care by not following NMC
guidance or record keeping
(3) The District Nursing Services are compromising patient care by not following NICE
guidelines,
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.
YOUR RESPONSE
You are under a duty to respond to this report within 56 days of the date of this report,
namely by .7 June 2016 |, 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
| have sent a copy of my report to the Chief Coroner, to the family, to the relevant CCGs
and the CQC. For the avoidance of doubt the document is only provided to the CCGs
and the CQC for information purposes and to inform their future care provision
negotiations.
{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, ¥qu may make representations to me, the coroner, at the time of your
response, fe) publication of your response by the Chief Coroner.
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