Prevention of Future Deaths reports · 2018
Regulation 28 report to prevent future deaths, reference 2018-0207, written 29 Jun 2018. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 29 Jun 2018 |
|---|---|
| Reference | 2018-0207 |
| Deceased | Ashley Notson |
| Coroner | Peter Dean |
| Coroner area | Suffolk |
| Category | Hospital Death (Clinical Procedures and medical management) 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
THIS REPORT IS BEING SENT TO:
1. Department of Health.
2. Care Quality Commission.
CORONER
lam Dr Peter Dean, senior coroner for the coroner area of Suffolk
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.
INVESTIGATION and INQUEST
At the conclusion of the inquest into the very sad death of ASHLEY ERNEST NOTSON,
| recorded a conclusion of ‘Accidental death’. The cause of death was found to be: 1a
Hypoxic brain injury due to 1b Hypoxic cardiac arrest due to 1c Upper airway obstruction
from inhalation of a foreign body, with Autistic spectrum disorder in Part Il.
CIRCUMSTANCES OF THE DEATH
Ashley Notson died in very tragic circumstances at the age of 55 after a period of time in
hospital where he was taken after choking on a piece of meat at the care home in which
he lived. Attempts to resuscitate him, including Heimlich manoeuvres, were conducted
by a staff member on duty at the care home who had previously had training in first aid
but, sadly, Mr Notson passed away from hypoxic brain injury resulting from the choking
episode.
a
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 could occur unless action is taken. In the
circumstances it is my statutory duty to report to you.
The MATTERS OF CONCERN are as follows. —
The inquest heard that the law currently does not require care providers to ensure that
carers in a care home have had first aid training. Fortunately, the carer on duty at the
time of the incident was trained in first aid and did what he could to assist Ashley, but a
similar situation could clearly arise in another care home without such a suitably trained
carer present.
The inquest also heard that, at this care home, all carers carry a mobile or portable
telephone so that they can summon assistance if an incident occurs without having to
leave the person they are looking after, but that this was not a legal requirement either.
ACTION SHOULD BE TAKEN
Although appropriate assistance was given promptly here, despite the tragic outcome, it is
clearly foreseeable that additional problems could occur in another care home if carers did
not have first aid training or carry a mobile or portable telephone. To try to reduce the risk
of future tragedies and fatalities occurring, | would ask CQC and the Department of Health
to give consideration to amending the current legal framework to ensure that care staff are
all suitably trained in first aid and carry mobile telephones with which they can summon
immediate assistance if an incident occurs without having to leave the side of the person
they are trying to assist.
7 [Your RESPONSE
You are under a duty to respond to this report within 56 days of the date of this report,
Your response must contain details of action taken or proposed to be taken, setting out
Similarly, you are 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
namely by the 24" of August 2018. |, the coroner, may extend the period.
the timetable for action. Otherwise you must explain why no action is proposed.
8 | COPIES and PUBLICATION
| have sent a copy of my report to the Chief Coroner and to the following Interested
Persons:
Mr Notson’s family.
interest. You may make representations to me, the coroner, at the time of your
response, about the release or the publication of your response.
4]
L9 | Dr Peter Dean {| U',}<@..29-6-18
See every Prevention of Future Deaths report matching Hospital Death (Clinical Procedures and medical management) related deaths, and how often a new one appears.
What would an alert for this have sent me? Search the full text
Free to try — the preview shows the real matches and how many arrived in the last 12 months. Your first email alert is free.
These reports are published by the Chief Coroner's office at judiciary.uk and are © Crown copyright. The text here is reproduced from the published PDF so it can be searched. If something on this page is wrong, or you are a person named in it and want it reviewed, email drcjar@gmail.com and we will act promptly.