Prevention of Future Deaths reports · 2017
Regulation 28 report to prevent future deaths, reference 2017-0437, written 6 Jul 2017. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 6 Jul 2017 |
|---|---|
| Reference | 2017-0437 |
| Deceased | John Ramsden |
| Coroner | Jennifer Leeming |
| Coroner area | Manchester (West) |
| Category | Community health care and emergency services 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 Chief Executive, Agrade Community Care Services, Unit 128, Coney
Green Business Centre, Wingfield View, Chesterfield S45 9]W
CORONER
I am M Jennifer Leeming, HM Senior 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 3™ of February 2017 I commenced an investigation into the death of
John Ramsden, 82 years, born 23" August 1934. The investigation concluded
at the end of the Inquest on 5" July 2017.
The medical cause of death was:-
Ia Bronchopneumonia
II Dementia (terminal)
The conclusion of the Inquest was John Ramsden died of Natural Causes.
CIRCUMSTANCES OF THE DEATH
John Ramsden who suffered from dementia was subject to a Deprivation of
Liberty Safeguarding Authorisation at Lever Edge Care Home where he resided.
On the 8" January 2017 he was seen by a Doctor and medication for a
suspected Urinary Tract Infection was prescribed. The pharmacy did not deliver
that medication until 9 January 2017 and it was not therefore administered
until that date. Whilst John Ramsden was a patient at Lever Edge Care Home
his eldest daughter was consulted about his care but his other two daughters
were not so consulted.
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 evidence at the Inquest was that John Ramsden’s eldest daughter
was consulted about decisions to his care. However, John Ramsden’s
other two daughters were not consulted, particularly about his end of life
care and about whether he should be admitted to hospital for treatment
or not.
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.
YOUR RESPONSE
You are under a duty to respond to this report within 56 days of the date of this
report, namely by 31° August 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:-
1. ES (augh ter)
2. (ugh ter),
3, I (22h)
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.
Signed
( ‘a
M seen {Senior Coroner | |
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