Prevention of Future Deaths reports · 2017
Regulation 28 report to prevent future deaths, reference 2017-0074, written 16 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 | 16 Mar 2017 |
|---|---|
| Reference | 2017-0074 |
| Deceased | Clive Davies |
| Coroner | Andrew Barkley |
| Coroner area | South Wales Central |
| 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.
ANNEX A
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:
1. The Chief Executive of the Cwm Taf University Health Board
2. Minister of Health, Welsh Assembly Government
3. The Chief Coroner
1
CORONER
I am Andrew Barkley, Senior Coroner, for the coroner area of South Wales Central.
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 the 7th September 2016 I commenced an investigation into the death of Clive Davies.
The investigation concluded at the end of an inquest on the 15th March 2017. The
conclusion of the inquest was that of a narrative conclusion “Clive Davies died from the
complication of a head and neck injury which he sustained when he fell down the stairs
at his home address. The precise cause of the fall is unknown but is likely to have been
due to the medical condition which he suffered with.”
4
CIRCUMSTANCES OF THE DEATH
The deceased, who was known to have fallen several times since January 2016 and
who was generally in poor health, fell down the stairs at his home address on the 22nd
August 2016 he was conveyed to the Royal Glamorgan Hospital where a CT scan
revealed serious head injury (Intraventricular Haemorrhage) and a Cervical Spine
Fracture. Initially his observations were stable but a noticeable deterioration occurred on
the 24th August where upon a further CT head scan took place which revealed
progression of the intracranial bleed. He was not deemed suitable for surgical
intervention. His condition fluctuated and he appeared to be making some progress
although his family maintained that he was deteriorating throughout his hospital
admission. In the early of 30th August he was found unresponsive in his bed and could
not be revived. He was declared deceased shortly after.
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 as follows
The MATTERS OF CONCERN are as follows. –
[BRIEF SUMMARY OF MATTERS OF CONCERN]
(1) The evidence revealed that there were generalised failures in relation to routine
observations conducted upon Mr Davies – both NEWS observations and “neuro”
observations. On the 29th August neuro observations were performed at 0600
hours but were then supposed to be conducted every 4 hours but were not at
10AM 2PM 6PM and 10PM. The final neuro observation was conducted at
11PM and no explanation could be found as to why this had not happened. The
last NEWS score was conducted at 1745 on the 29th August but not thereafter.
Upon review it appeared that that NEWS score which was undertaken was
incorrectly calculated meaning that he was not subject to a medical review when
clearly he should have been. It was accepted at the inquest that this was a
failure for which no explanation was forthcoming.
6
ACTION SHOULD BE TAKEN
In my opinion action should be taken to prevent future deaths and I believe you and your
organisation 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 7th June 2017. 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, the Health Minister of the Welsh
Assembly Government and the family who may find it useful or of interest.
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
16th March 2017 SIGNED:
Mr Andrew Barkley
HM Senior Coroner
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