Prevention of Future Deaths reports · 2017
Regulation 28 report to prevent future deaths, reference 2017-0086, written 23 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 | 23 Mar 2017 |
|---|---|
| Reference | 2017-0086 |
| Deceased | Marian Dale |
| Coroner | Alison Mutch |
| Coroner area | Manchester South |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| Organisation named | Stockport 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
REGULATION 28 REPORT TO PREVENT FUTURE DEATHS
THIS REPORT IS BEING SENT TO: The Chief Freputive of Stockport NHS
Foundation Trust.
1 CORONER
lam Alison Mutch, Senior Coroner, for the coroner area of South Manchester
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
3 | INVESTIGATION and INQUEST
On 22™ November 2016 | commenced an investigation into the death of
Marian Dale. The investigation concluded on the 3° March 2017 and the
conclusion was one of died from sepsis, a recognised complication of cellulitis,
foilowing trauma to the legs. The medical cause of death was 1a
Sepsis;1bCellulitis;1c Trauma to the leg
4 | CIRCUMSTANCES OF THE DEATH
Marian Dale lived independently at her home address. She injured both her legs
in separate accidents. She was treated by the District Nursing Team for one of
the injuries. Both legs developed cellulitis and she was admitted to Stepping Hill
Hospital. She was treated with antibiotics for the cellulitis. She developed sepsis
and died at Stepping Hill Hospital on the 17th November 2016.
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. —
Marian Dale had been visited on a regular basis by the District Nursing Team.
However, they were unable to give evidence of the condition of her legs and
treatment on their visits prior to her death. This was due to the fact that all
notes were retained at the patient’s address until a full sheet in the hand held
notes was completed. There was no system for a contemporaneous record to
be held centrally. Her notes had not been retrieved after her death and there
was no system in place to ensure that happened.
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 16% May 2017. |, 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.
COPIES and PUBLICATION
| have sent a co {o the Chief Coroner and to the following Interested
Persons namel son of the deceased, who may find it useful or of
interest.
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.
Alison Mutch OBE
HM Senior Coroner
23" March 2017
tN
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