Prevention of Future Deaths reports · 2018
Regulation 28 report to prevent future deaths, reference 2018-0065, written 1 Mar 2018. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 1 Mar 2018 |
|---|---|
| Reference | 2018-0065 |
| Deceased | Cyril Anderton |
| Coroner | Sean McGovern |
| Coroner area | Warwickshire |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | none published |
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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. Chief Executive — George Eliot Hospital 1 | CORONER | am S McGovern, Senior Coroner, for the Coroner Area of Warwickshire 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 | concluded the investigation into Mr Anderton's death at an Inquest held on 1* March 2018.The conclusion of the inquest was a Narrative Verdict (Copy attached). 4 | CIRCUMSTANCES OF THE DEATH See Narrative Verdict 5 | 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) the failure of the medical staff to attempt CPR having consulted the wrong set of medical notes 6 | ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and | believe you as Chief Executive of the Trust 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 26" 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 1 have sent a copy of my report to the Chief Coroner and to the following persons (a) the family of Mr Anderton ( by email) and _(b) ( who brought this to my attention on behaif of his constituent | 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. stp 1° March 2018 a M bpvir Senior Coroner S McGovern
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