Prevention of Future Deaths reports · 2017
Regulation 28 report to prevent future deaths, reference 2017-0299, written 18 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 | 18 Oct 2017 |
|---|---|
| Reference | 2017-0299 |
| Deceased | Wycliffe Matthews |
| Coroner | John Pollard |
| Coroner area | Manchester (West) |
| Category | Care Home Health related deaths |
| 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 (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 Owner, Alexandra Grange Care Home, 8 Howard Street, Pemberton, Wigan_WN5 8BH CORONER I am John §S Pollard, Assistant Coroner for the Coroner Area of Manchester West. 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. INVESTIGATION and INQUEST On the 5" January 2017, I commenced an investigation into the death of Wycliffe Ashton Matthews, aged 91 years. The investigation concluded at the end of the inquest on the 29" September 2017. The conclusion of the inquest was accidental death contributed to by neglect. CIRCUMSTANCES OF THE DEATH On the 11" of December 2016 in Alexander Grange Care Home, he was hoisted three times in a standing hoist. On the first and second occasions he had difficulties and on the third occasion he let go of the hoist and sat back in the chair causing traumatic spinal cord injuries. This led to his death and pneumonia. 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. During the Inquest evidence was heard that:- i. The staff at the home seemed untrained or at least inadequately trained on the use of the hoist. ii. The staff failed to keep any, or any proper, note of the events which led to the death. ACTION SHOULD BE TAKEN In my opinion urgent action should be taken to prevent future deaths and I believe that you 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 December 12" 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. COPIES and PUBLICATION I have sent a copy of my report to the Chief Coroner and to the following Interested Persons:- (son) 1 2. EE (laughter) 5 a °°) T 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. John S Pollard, HM Assistant Coroner
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