Prevention of Future Deaths reports · 2018
Regulation 28 report to prevent future deaths, reference 2018-0004, written 4 Jan 2018. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 4 Jan 2018 |
|---|---|
| Reference | 2018-0004 |
| Deceased | Dylan Hill |
| Coroner | Tanyka Rawden |
| Coroner area | South Yorkshire (West) |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths · Other related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 3 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
REGULATION 28: REPORT TO PREVENT FUTURE DEATHS 1 2 3 REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: 1. Secretary of State for Health, Richmond House, 79 Whitehall, London, SW1A 2NS 2. Food Standards Agency, Aviation House, 125 Kingsway, London, WC2B 6NH CORONER Tanyka Rawden, Assistant Coroner for South Yorkshire (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 On 28 July 2015 an investigation was commenced into the death of Dylan Paul Hill aged 18 years. Following a post-mortem examination, the investigation concluded with an inquest on 19 and 20 December 2017. The inquest was assisted with evidence from the partner of Dylan Hill who was at the restaurant with him, representatives from Trading Standards and Environmental Heath, the owner of the restaurant and an expert, . The conclusion of the inquest was that Dylan Paul Hill died at Barnsley General Hospital of an anaphylactic reaction after eating a korma meal at a restaurant in Barnsley on 17.05.15. Dylan was served a korma containing almond powder. That powder contained almonds and peanuts. The restaurant was not aware the almond powder contained peanuts as it was not labelled and had been decanted into another container. Importantly, no steps had been taken by the restaurant to ascertain the ingredients of the almond powder. There was no allergen information on the menus or displayed in the restaurant Dylan didn’t have his EpiPen with him but it cannot be said this would have brought about a different outcome. 4 CIRCUMSTANCES OF THE DEATH Dylan Paul Hill was diagnosed with a peanut allergy at the age of ten. In consequence he had been issued with an adrenaline auto-injector (in this case an EpiPen). Mr Hill also suffered from asthma. On 17.05.17 Mr Hill and his partner went to a restaurant in Barnsley. Mr Hill ordered a Korma meal and became unwell after eating one or two mouthfuls. He asked the waiter whether the meal contained nuts and was told it did. After returning home a short time later Mr Hill collapsed and was confirmed dead on arrival at the local A&E Department. Pathology examination showed that Mr Hill had died of an anaphylactic reaction. Examination of the contents of the ingredients of the korma showed that the ‘almond powder’ contained 94% almonds and 6% peanuts. In evidence it was clear the restaurant did not know the ‘almond powder’ contained peanuts as the ingredients had not been checked on purchase, the powder had been decanted into an unlabeled container, and the packaging disposed of. 5 CORONER’S CONCERN During the course of the investigation my inquiries 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 MATTER OF CONCERN is as follows. – Evidence was given before the Court of an incident within the same premises in September 2014 where a curry containing nuts was given to a customer who had requested a nut free curry. That customer had an anaphylactic reaction and was taken to hospital where he made a full recovery. Evidence was also given that the Trading Standards department of the local council had not been told of this incident prior to the death of Mr Hill. Had they known, they would have arranged a priority visit. After Mr Hill's death the restaurant were issued a prohibition notice that they were not permitted to offer allergen free meals. Evidence was given that there are no procedures in place for such communications between the health services and Trading Standards in cases of non fatal anaphylactic reactions. In my opinion there is a risk that future deaths may occur unless cases of non fatal anaphylactic reactions caused by the ingestion of purchases from food business operatives are reported to those regulatory authorities responsible for the supervision and monitoring of food safety and hygiene. The question therefore arises as to whether the emergency services and health services within the area can work together to ensure that Trading Standards Departments are made aware of all anaphylaxis incidents relating to commercial premises so that the appropriate action can be taken as regards those premises. 6 ACTION SHOULD BE TAKEN In my opinion urgent action should be taken to prevent future deaths and I believe 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 1 March 2018. I may extend this period upon your application. 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 Person: , family representative. Others sent copies for information: 1. Chief Executive, Sheffield Teaching Hospitals NHS Foundation Trust 2. Chief Executive, Sheffield Children’s hospital, Sheffield, Western Bank, Sheffield, S10 2TH 3. Chief Executive, Barnsley District Hospital, Gawber Road, Barnsley, S75 2EP 4. Chief Executive, Clinical Commissioning Group, Sheffield, 722 Prince of Wales Road, Sheffield, S9 4EU 5. Chief Executive, Clinical Commissioning Group, Barnsley, 49/51 Gawber Road, Barnsley S75 2PY 6. Chief Executive, Yorkshire Ambulance Service, Springhill 2, Wakefield 41 Business Park, Brindley Way, Wakefield, WF2 0XQ 7. Chief Executive, Trading Standards, Sheffield City Council, 5th Floor, Howden House, Sheffield, S1 2SH 8. Chief Executive, Trading Standards, PO Box 602, Barnsley, S70 9FB 9. Environmental Health, Sheffield City Council, Staniforth Road, Sheffield, S9 3HD 10. Environmental Health, Barnsley Metropolitan Borough Council, Common Road, Brierley, Barnsley, S72 9EP 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. Mrs Tanyka Rawden 4 January 2018
3 responses published against this report on judiciary.uk. A response is a body's written reply to the coroner's concerns; publication is at the discretion of the Chief Coroner's office, so an absent response does not mean nobody replied.
) : ia Barnsley Hospital . @ = las ab as Quality in Care Barnsley Hospital [Vij NHS Foundation Trust Gawber Road | Barnsley $75 2EP \ } : ; Tel: 01226 730000 Fax: 01226 202859 Minicom: 01226 321014 MrsTanyka Rawden Assistant Coroner The Office of H.M Coroner The Medio-Legal Centre Watery Street Sheffield S3 7ET 5 March 2018 Our ref: RJ/KR Dear Mrs Rawden Re: Dylan Paul Hill (Deceased) May | thank you for including our Trust in the circulation list for the Regulation 28 that you issued on 5 January 2018, and forwarded to Secretary of State for Health and Food Standards Agency. Whilst the Regulation 28 does not require a formal response from our Trust we have taken a decision to respond to the points that you have raised to improve working relationships between the Trust Trading Standards at Barnsley Metropolitan Council to improve the safety and care of people in the Barnsley locality. The purpose of my letter is to inform you that Barnsley Hospital NHS Foundation Trust has taken the following action to address the Coroner’s concerns that were provided in your letter (dated 5 January 2018) and can be responded to as follows: Evidence was also given that the Trading Standards department if the local council had not been told of this incident prior to the death of Mr Hill. Had they known, they would have arranged a priority visit. Our anaphylaxis draft protocol has been reviewed and updated in accordance with our internal governance processes (see enclosure 1). Evidence was given that there are no procedures in place for such communications between the health services and Trading Standards in cases of non fatal anaphylactic reactions. Our revised anaphylaxis draft protocol includes a referral form to inform Trading Standards of cases of anaphylactic reaction as a result of consuming food from commercial premises. In my opinion there is a risk that future deaths may occur unless cases of non fatal anaphylactic reactions caused by the ingestion of purchases from food business operatives are reported to those regulatory authorities responsible for the supervision and monitoring of food safety and hygiene. The enclosed protocol has a clear algorithm on medicine management and how the detail of the consumption at the commercial premises is communicated to the local authority to ensure the timely communication of potential risks. jg ee ee ee en ae www.barnsleyhospital.nhs.uk — (<) @barnshospital —[}_ www.facebook.com/barnsleyhospital The question therefore arises as to whether the emergency services and the health services within the area can work together to ensure that Trading Standards Departments are made aware of all anaphylaxis incidents relating to commercial premises so that the appropriate action can be taken as regards these premises. Our enclosed draft protocol has been circulated with the listed interested parties named in this Regulation 28 letter. The draft protocol will be taken to the Trust’s Clinical Business Unit Governance Meeting on 23 March 2018 for it to be reviewed and ratified we will forward you the final protocol when this has been agreed. Yours sincerely VAD, Dr Richard Jenkins Chief Executive Enclosure: Barnsley Hospital NHS Foundation Trust’s Anaphylaxis (Draft Protocol) Copy to: Chief Executive, Sheffield Teaching Hospitals NHS Foundation Trust Chief Executive, Sheffield Children’s Hospital, Sheffield, Western Bank, Sheffield $10 2TH Chief Executive, Clinical Commissioning Group, Sheffield, 772 Prince of Wales Road, Sheffield S9 4EU Chief Executive, Clinical Commissioning Group, Barnsley, 49/51 Gawber Road, Barnsley S75 2PY Chief Executive, Yorkshire Ambulance Service, Springhill 2, Wakefield, 41 Business Park, Brindley Way, Wakefield WF2 0XQ Chief Executive, Trading Standards, Sheffield City Council, 5" floor, Howden House, Sheffield $1 2SH Chief Executive, Trading Standards, PO Box 602, Barnsley S70 9FB Environmental Health, Sheffield City Council, Staniforth Road, Sheffield S9 3HD Environmental Health, Barnsley Metropolitan Borough Council, Common Road, Brierley, Barnsley S72 9EP Page 2 of 2
BGR From Steve Brine MP rE Parliamentary Under Secretary of State for Public Health and Primary Care Department of Health , ; 39 Victoria Street London SW1H OEU 020 7210 4850 PFD-1113293 lV, Cees Mrs Tanyka Rawden 88 MAR 2919 HM Assistant Coroner, South Yorkshire (West) Office of HM Coroner The Medico-Legal Centre Watery Street Sheffield S3 7ET poe Mr fawber, hank you for your letter of 5 January to the Secretary of State about the death of Mr Dylan Paul Hill. I am responding as Minister with responsibility for public health. I was extremely saddened to read of the circumstances surrounding Mr Hill’s death. Please pass my condolences to his family and loved ones. I can only imagine how difficult a time this must be for them. Your Report raises the concern that future deaths might occur unless cases of non-fatal anaphylaxis brought on by the ingestion of food consumed from commercial premises are reported to the relevant regulatory authorities overseeing food safety and hygiene. My officials have made enquiries with the Food Standards Agency (FSA), to which you also issued your Report, and I understand the Agency shares your concerns. The FSA wishes to set up a cross-government discussion to consider this matter further. I hope this will be a welcome development and will provide assurance that the matter will be considered carefully. I am advised that the FSA will update you on the outcome of discussions in due course. At a local level, I am advised that Barnsley and Sheffield are working to explore the development of local notification systems in both primary and secondary care settings. This includes collaborative working between Barnsley and Sheffield acute trusts to ensure there is consistency in the mechanisms being put in place, as well as consideration of the best way to raise awareness among GPs. This issue and the progress made on measures to address it will be monitored by the Sheffield and the Barnsley Health Protection Boards. The local NHS is mindful of any action that might be taken at a national level and clearly any developments will inform future local action. However, I hope you are assured the local NHS is working to explore what measures can be put in place at a local level. I hope this response is helpful. Thank you for bringing the circumstances of Mr Hill’s death to our attention.
» Food From Jason Feeney CBE Standards Chief Executive ~ Agency Mrs Tanyka Rawden HM Assistant Coroner, South Yorkshire (West) Office of HM Coroner | The Medico-Legal Centre | Watery Street Fare Sheffield — $3 7ET Date: 28 February 2018 Our Ref: BC2018/0013 Dear Mrs Rawden, Thank you for sending the Regulation 28: Report to Prevent Future Deaths to the Food Standards Agency, following an investigation into the death of Mr Dylan Paul Hill, which concluded with an inquest on 19 and 20 December 2017. . | am saddened to hear about the death of Mr Hill, and my thoughts are with his friends and family. We are aware that the Department of Health and Social Care will be responding to you regarding measures to be put in place at a local level. In March, we will be meeting with representatives from other government departments (including the Department of Health and Social Care and Public Health England) and organisations involved in food allergy to discuss how we can better tackle the issue. We would, of course, welcome your contribution if you wouid like to take part in such discussions. Alternatively, we will keep you in touch with developments on this issue. On raising awareness about food allergy, we provided stakeholders with key messaging before and after the allergen information and labelling rules became enforceable in December 2014. These have been particularly around the changes in legislation, detailing the obligations and responsibilities of the business, but also to let consumers know how to look for allergen information. In relation to enforcement of allergens information and labelling rules, we have provided clarification in the Food Law Code of Practice and associated Practice Guidance, implemented in 2017, and are looking to further strengthen these documents to address allergen management and cross contamination issues. Later this year, we will be placing Floors 6 & 7, Clive House A Ss 70 Petty France, London SW1H 9EX Wis food.gov.uk/ratings more emphasis on reporting of near misses and deaths from food allergy in the Practice Guidance. We will also be writing to local authorities to highlight lessons learnt, and reinforce our expectations on good allergen management practices. Food allergy remains one of the FSA's priority areas and we will continue to focus our efforts to help consumers make informed food choices, to help businesses to understand and comply with legislation relating to allergen information and labelling. Chun-Han Chan, who leads in the Food Allergy & Intolerance Branch on Allergen Legislation and Risk Assessment, will be organising the cross-Government discussions. | would be grateful if you could contact her (chun-han.chan@food.gov.uk) if you wish to be involved in the discussions. Yours sincerely, Jason Feeney CBE
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