Prevention of Future Deaths reports · 2018

Adrian King

Regulation 28 report to prevent future deaths, reference 2018-0061, written 27 Feb 2018. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.

Date of report27 Feb 2018
Reference2018-0061
DeceasedAdrian King
CoronerAndrew Haigh
Coroner areaStaffordshire (South)
CategoryOther related deaths
Sourcejudiciary.uk record · original PDF
Responses published1

The report

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
THIS REPORT IS BEING SENT TO:

Rt Hon B Johnson MP
Secretary of State for Foreign and Commonwealth Affairs

Foreign Office
King Charles Street
London SW1A 2AH
1 | CORONER
| am Mr Andrew Haigh senior coroner for the coroner area of Staffordshire South
2 | 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.
3 | INVESTIGATION and INQUEST
On 4" July 2017 | commenced an investigation into the death of Adrian Nicholas
KING aged 39 years. The investigation concluded at the end of the inquest on 15"
February 2018. The conclusion of the inquest was ‘Collapse in hot desert followed
by limited medical treatment’
4 | CIRCUMSTANCES OF THE DEATH
Mr King died in hospital in Egypt on 29th May 2017. On 18th May he had gone on
an excursion which included riding a quad bike into the desert. He had become
unwell and collapsed. There were problems with the insurance to cover his medical
treatment. He died from kidney failure.
5 | CORONER’S CONCERNS

During the course of the inquest the evidence revealed a matter 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. —

The indication given to me in evidence at the inquest was that the extent of Mr
King’s medical treatment had been affected by problems with his insurance
cover. Family members told me that when they became aware of his illness
and hospitalization in Egypt they made numerous telephone calls attempting
to speak to the consulate in Egypt in an effort to assist with what was going
on. These calls were either not answered or curtailed very quickly without
progress being made. It is not possible to say if it is likely that Mr King could
have been saved but this remains an unanswered possibility. However it
strikes me as important that if people in Britain are seeking to contact a
British embassy or consulate abroad in order to assist with medical treatment
for someone who is ill in that foreign country then the channel of
communication should be open.

For the avoidance of doubt this concern relates to events prior to death. It has
nothing to do with Coroners seeking to obtain information from abroad after a body
from abroad comes back to England and Wales. That system is presently managed
by and | am grateful for the assistance it provides on a regular
basis.

ACTION SHOULD BE TAKEN
In my opinion action should be taken to prevent future deaths and | believe you and
your organisation 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 24'" April 2018. |, 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

Persons :

Adrian’s mother)
(Adrian’s father)
| have also sent it tol) who may find it useful or of interest.

| 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.

27,2.2018

Andrew A Haigh

HM Senior Coroner
Staffordshire (South)

Coroner’s Office

No 1 Staffordshire Place
Stafford

ST16 2LP

Tel No: 01785 276127
sscor@staffordshire.gov.uk

Responses

1 response 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.

Response from Foreign Commonwealth Office (PDF)
+

‘é April 2018 Seat *
Mr Andrew A Haigh vehi g Ith
HM Senior Coroner ommonwea
Coroner’s Office Office
Noi Staffordshire Place ‘iit uidles tran
Stafford London SW1A 2AH
ST16 2LP

Secretary of State

Thank you for providing me with a copy of your Regulation 28 report of 27 February
regarding the death of Mr Adrian King in Egypt and for alerting me to the difficulties
Mr King’s family say they experienced in communicating with the Foreign and
Commonwealth Office (FCO).

Consular staff were in daily contact with Mr King’s family from 25 May 2017. But I
accept that more effort should have been made to reach out to the family more
quickly once they were notified of Mr King’s admittance to Al Kouther hospital in
Hurghada on 22 May 2017. The Consular Regional Operations Manager and consular
staff have since been reminded of the policy guidance and best practice and to ensure
appropriate action is taken in a timely manner for all cases. If the family wish to
provide more detail of the dates and times where they were not able to get hold of a
member of the Consular team we will of course investigate further.

In line with our consular policy, the support to Mr King’s family from our staff in
Cairo and London included contacting the hospital, insurance company and Mr
King’s father, brother and friend. On 28 May, our embassy’s Consular Warden visited
Mr King and sought updates from the hospital manager and the doctors overseeing
Mr King’s care at El Queseri hospital. I understand that these updates were shared
with Mr King’s family.

From reviewing the details of these contacts it is clear that the insurance company’s
refusal to cover Mr King’s medical costs stem from a pre-existing condition that they
told us had not been declared to them. As consular staff are not medically trained
they are not able to change decisions made by insurance companies or hospitals. So it
appears that even if FCO officials had been in contact with the family sooner, it
would not have affected the decisions made by the hospital and insurance company
in Mr King’s case.

Whether or not consular officers can influence treatment decisions in foreign ;
hospitals, it is very important to me that British people are able to make contact with
our consular staff when they need our support. Since July 2017 all consular calls to

the FCO in London and to British embassies and consulates are answered at one of
our in-house Consular Contact Centres.

These centres provide a 24-hour, seven day a week service for British people
anywhere in the world, usually for the cost of a local or national phone call. They will
directly help the caller if possible, or ask a member of the consular staff in the
relevant country to provide in-person help when that is necessary. They can also
provide information and advice about the consular services available at our
embassies and consulates.

The FCO’s Consular Strategy 2016-2020! sets out our commitment to reducing the
number of preventable consular cases before they happen, and helping to minimise
the risk to British people overseas. One of our current prevention priorities is to
encourage an increased proportion of British travellers and expats to take out
appropriate travel insurance before they travel. This includes using communications
campaigns to sensitise British people to the need to purchase insurance that is valid
for the activities they are undertaking overseas. We are also strengthening our
relationships with the insurance industry, and identifying opportunities for joint-
working to improve the insurance offer for British nationals.

For more details on the standard of consular assistance that family members can
expect following the hospitalisation of a loved one overseas, please refer to our guide?

for British people overseas.
Us ee %y ene ile |
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"aut gee es ea Oa
ay

THE RT HON BORIS JOHNSON MP

1
https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file
/519687/Consular_ Services 2016-2020.pdf

2 https://assets.publishing.service.gov.uk/government
/uploads/system/uploads/attachment_data/file/584047/FCO Brits Abroad _web130117.pdf

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