Prevention of Future Deaths reports · 2017
Regulation 28 report to prevent future deaths, reference 2017-0189, written 14 Jun 2017. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 14 Jun 2017 |
|---|---|
| Reference | 2017-0189 |
| Deceased | Alaanuloluwa Joseph |
| Coroner | Sean Cummings |
| Coroner area | West London |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| Organisation named | The Hillingdon 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 NOTE: This form is to be used after an inquest. REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: Shane DeGaris, Chief Executive Hillingdon Hospitals NHS Foundation Trust CORONER !am Dr Sean Cummings Assistant Coroner for the Coroner Area of West London 3 | INVESTIGATION and INQUEST 4 | CIRCUMSTANCES OF THE DEATH 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. Inquest into the death of Alaanuloluwa Joseph Master Alaanuloluwa Joseph died from sepsis, lung abscess and bacterial pneumonia at Great Ormond Street Hospital! on the 22.4 December 2015. He had been admitted to the Hillingdon Hospital during the early hours of the same day. CORONER’S CONCERNS Evidence was heard that indicated that accurate monitoring and recording of fluid intake and output was not undertaken. Evidence was also heard that fluid management in sepsis is of critical importance. ACTION SHOULD BE TAKEN To review the management of sick children in the Paediatric Accident and Emergency Department to ensure that all those suspected of having infection or sepsis must have fluid balance charts completed. YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 9" August 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 copy of my report to the Chief Coroner and to the following Interested Person: Adekola Joseph 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 ér\the publication of your response by the Chief Coroner. 14! June 2017 Oy te Cann j | 7 Ncsdhech Cw OAL
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