Prevention of Future Deaths reports · 2017
Regulation 28 report to prevent future deaths, reference 2017-0064, written 6 Mar 2017. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 6 Mar 2017 |
|---|---|
| Reference | 2017-0064 |
| Deceased | John Atkin |
| Coroner | Anna Crawford |
| Coroner area | Surrey |
| Category | Other 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.
IN THE SURREY CORONER’S COURT
IN THE MATTER OF:
__________________________________________________________
The Inquest Touching the Death of John Anthony Atkin
A Regulation 28 Report – Action to Prevent Future Deaths
__________________________________________________________
1
THIS REPORT IS BEING SENT TO:
Managing Director Millbrook Healthcare Limited
2 CORONER
Ms Anna Crawford, HM Assistant Coroner for Surrey
3 CORONER’S LEGAL POWERS
I make this report under paragraph 7(1) of Schedule 5 to The Coroners and
Justice Act 2009.
4
INVESTIGATION and INQUEST
An investigation was commenced on 4 March 2016 and the inquest into the
death of John Atkin was opened on 13 May 2016. It was resumed on 8
February 2017 with a jury. The jury returned their conclusion on the 13th
February 2017, having been in retirement for 4 hours and 53 minutes.
They found the medical cause of death to have been:
1a. Staphylococcal Septicaemia
1b. Dog bite wound of the hand
II. Diabetes Mellitus
They concluded with a short form conclusion of ‘Accident’.
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5 CIRCUMSTANCES OF THE DEATH
John Atkin was a Driver/Technician for a company called Millbrook Healthcare
Limited (Millbrook), a company that delivers and installs healthcare equipment
at service-users’ homes. Healthcare professionals use a web-based system to
order equipment from Millbrook on behalf of their patients/clients. The court
heard that, due to the nature of its business, a significant proportion of the
people to whom Millbrook delivers have difficulties with their mobility.
On 23 February 2016 Mr Atkin was tasked to deliver and to install an item of
equipment at the home of an individual who had recently undergone an
amputation of her leg. On the job sheet Mr Atkin received he was instructed to
go directly into the service-user’s home because she could not come to the
door. On arrival he duly entered the premises where he was bitten by the
service-user’s spaniel dog.
The court heard that Mr Atkin then returned to work and the wound was
washed and dressed by the first aider. The first aider advised Mr Atkin to go to
hospital but he declined. He continued to go to work over the next few days
but began to feel increasingly unwell. On 26 February 2016 he left work early
complaining of feeling ill. On 27 February 2016 he was found deceased at his
home address.
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6 CORONER’S CONCERNS
The court heard evidence that Millbrook expects the healthcare professionals
ordering a particular piece of equipment to assess whether the service-user’s
home poses any potential hazards to Millbrook’s delivery drivers, and to
inform Millbrook of any such hazards when they place an order.
During the course of the inquest the court heard from the two occupational
therapists who were involved in prescribing and ordering the piece of
equipment that Mr Atkin delivered on 23 February 2016. They told the court
that they do not always assess service-users at their home addresses and do not
routinely ask service-users about the presence of pets in their homes. They
were not aware that they were expected to assess potential hazards to
Millbrook’s delivery drivers, and said that they only passed on such
information if they were aware of it.
The court heard evidence that Millbrook is due to roll out a new system which
will require healthcare professionals ordering equipment to specify whether or
not there is a dog at a service-user’s address. The company has not carried out
any consultation with its clients regarding the introduction of the new system,
and whether it is realistic to expect healthcare professionals to obtain this
information from their patients/clients.
The court also heard evidence from an inspector at the Health and Safety
Executive. As part of his investigation into Mr Atkin’s death he had carried out
enquiries with the Royal Mail and a representative of the white goods industry
with respect to industry practice. He told the court that members of the
industry did not routinely ask in advance about potential hazards at addresses,
but that it was accepted practice at both the Royal Mail and within the white
good industry to have a policy in place to prevent employees from crossing the
threshold into a person’s home until they had made direct contact with the
homeowner.
The MATTERS OF CONCERN are:
- Millbrook currently operates on the basis of an inaccurate assumption
that enquiries with regard to whether there are any hazardous dogs at a
service-user’s address are carried out by the healthcare professionals
who order the equipment from them.
- There is no policy in place at Millbrook which prevents driver/
technicians from entering a service-user’s address before they have
made direct contact with the home owner.
Consideration should be given to whether any steps can be taken to address the
above concerns.
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7 ACTION SHOULD BE TAKEN
In my opinion action should be taken to prevent future deaths and I believe that
the people listed in paragraph one above have the power to take such action.
8 YOUR RESPONSE
You are under a duty to respond to this report within 56 days of its date; I may
extend that period on request.
Your response must contain details of action taken or proposed to be taken,
setting out the timetable for such action. Otherwise you must explain why no
action is proposed.
9 COPIES
I have sent a copy of this report to the following:
1.
2. Surrey County Council
3. St. George’s University Hospitals NHS Foundation Trust
4.
5. Health and Safety Executive
6. The Chief Coroner
In addition to this report, I am 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,
at the time of your response, about the release or the publication of your
response by the Chief Coroner.
10 Signed:
ANNA CRAWFORD
DATED this 6th day of March 2017
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