Prevention of Future Deaths reports · 2017
Regulation 28 report to prevent future deaths, reference 2017-0282, written 7 Oct 2017. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 7 Oct 2017 |
|---|---|
| Reference | 2017-0282 |
| Deceased | Marcin Mazurek |
| Coroner | Nicholas Rheinberg |
| Coroner area | Preston and West Lancashire |
| 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.
REGULATION 28: REPORT TO PREVENT FUTURE DEATHS
THE REPORT IS BEING SENT TO:
NHS England, Skipton House, 80 London Road, London SE1 6LH
1
CORONER
I am Nicholas Leslie Rheinberg, assistant coroner for the coroner area of Preston and
West Lancashire
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 7th September 2015 an investigation was commenced into the death of Marcin
Miroslaw Mazurek aged 32. The investigation concluded at the end of the inquest on 4th
October 2017. The conclusion of the inquest was that the deceased had died by
hanging. The jury further found that the deceased had spent an inappropriately long time
in segregation, that there had been a failure in the proper implementation of ACCT
procedures, with no multidisciplinary working and no involvement of mental health and
inadequate reporting by discipline and medical teams.
4
CIRCUMSTANCES OF THE DEATH
The deceased had become mentally unwell which condition was exacerbated by a very
long period in segregation. He began to self-harm and ultimately hanged himself.
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. –
(1) Medical record keeping was of very poor quality
(2) The daily medical checks in segregation by members of the nursing team and the tri-
weekly checks by the GP team, were frequently not recorded in the medical notes and /
or did not take place.
6
ACTION SHOULD BE TAKEN
The medical notes of prisoners are often of a poor quality, particularly in the realms of
mental health. Although it is the professional responsibility of doctors and nurses to
make adequate entries in the medical records of prisoners, nevertheless you might wish
to consider a universal system of training and audit across the prison estate in relation to
medical note recording.
In my opinion action should be taken to prevent future deaths and I believe 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 [4th December 2017. I, the coroner, may extend the period.
1
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 and to the following Interested
Persons namely the legal representatives of the family of the deceased, the Prison
Service and the current Healthcare provider.
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
Dated 7th October 2017 SIGNED
Assistant Coroner
2
See every Prevention of Future Deaths report matching Hospital Death (Clinical Procedures and medical management) related deaths, and how often a new one appears.
What would an alert for this have sent me? Search the full text
Free to try — the preview shows the real matches and how many arrived in the last 12 months. Your first email alert is free.
These reports are published by the Chief Coroner's office at judiciary.uk and are © Crown copyright. The text here is reproduced from the published PDF so it can be searched. If something on this page is wrong, or you are a person named in it and want it reviewed, email drcjar@gmail.com and we will act promptly.