Prevention of Future Deaths reports · 2018
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 report | 27 Feb 2018 |
|---|---|
| Reference | 2018-0061 |
| Deceased | Adrian King |
| Coroner | Andrew Haigh |
| Coroner area | Staffordshire (South) |
| Category | Other related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
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
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.
+ ‘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 | ] "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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