Prevention of Future Deaths reports · 2018
Regulation 28 report to prevent future deaths, reference 2018-0221, written 9 Jul 2018. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 9 Jul 2018 |
|---|---|
| Reference | 2018-0221 |
| Deceased | Robert Power |
| Coroner | Katy Skerrett |
| Coroner area | Gloucestershire |
| Category | Care Home Health related deaths |
| Organisation named | North Bristol NHS Trust |
| 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.
4 CORONER 2 CORONER'S LEGAL POWERS H M Senior Coroner for Gloucestershire Ms Katy Skerrett REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: Chief Executive Ms A Young, North Bristol NHS Trust, Southmead Hospital. Southmead road, Bristol BS10 5NB | am Katy Skerrett, Senior Coroner for Gloucestershire. | 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 the 22" May 2017 | commenced an investigation into the death of Robert Andrew Power. The investigation concluded at the end of the inquest on the 4"" May 2018. The conclusion of the inquest was natural causes. The medical cause of death was 1A Bronchopneumonia and urinary tract infection, 1B Multiple Sclerosis. CIRCUMSTANCES OF THE DEATH Robert Andrew Power “Robert” was a 49 year old man who lived in a care home specialising in neurological conditions. He had a history of significant drug and alcohol abuse. In 2007 he suffered a marked change in his physical abilities, and he underwent extensive investigations. He was diagnosed with gliomatosis cerebri, and discharged to a terminal care home. This diagnosis was incorrect. In 2014 his GP requested further assessment of Robert. Neurological opinion was sought, and it was determined that Robert had suffered significant damage to his brain, and had a chronic undefined inflammatory condition affecting his brain. In July 2015 Robert was admitted to a care home speciatising in neurological management. Thereafter whilst Robert's condition remained relatively stable, he was admitted to hospital on multiple occasions suffering with aspiration pneumonia, and / or seizure activity. Following ongoing deterioration, and after discussion with his family, it was agreed there would be no further escalation of treatment in the event of further deterioration. On the 12" April 2017 Robert was admitted to hospital suffering with aspiration pneumonia. He was discharged on the 4” May 2017 for palliative care. His condition steadily deteriorated. He was regularly reviewed by his GP. Robert passed away on the 17" May 2017. not lost to follow up care. It is acknowledged that significant steps have already been made. 6 ACTION SHOULD BE TAKEN During the course of the inquest the evidence revealed a matter giving rise to concern. The MATTER OF CONCERN was as follows. - Robert whilst being treated as a patient by the trust was essentially lost to follow up between 2007 - 2015. No explanation was given as to why this happened. For the reasons given in my summary of evidence | determined that there was no evidence that this area of concern had any direct causative impact on Robert’s death. However in my opinion there is a risk that future deaths may occur unless action is taken to ensure that outpatients are In my opinion action should be taken to prevent future deaths and I believe you have the power to take such action. a YOUR RESPONSE ee Gloucestershire Coroner's Court, Corinium Avenue, Barnwood, Gloucester, GL4 3D) Tel 01452 305661 | Fax 01452 412618 | acknowledge receipt of your submissions dated 18" May 2018. You are under a duty to respond to this report within 56 days of the date of this report, namely by 4pm 27" August 2018 if there are any additional submissions that have not already been made, |, 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 I have sent a copy of my report to the Chief Coroner and to the following Interested Persons (1) (2) Chief Executive Mr Jones, Ramsay Health Care, Level 18, Tower 42, 25 Old Broad Street, London EC2N 1HQ lam 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. Dated 9 ly 2018 Signature. Ms K Skerrett Senior Coroner for Gloucestershire Gloucestershire Coroner's Court, Corinium Avenue, Barnwood, Gloucester, GL4 3DJ Tel 01452 305661 | Fax 01452 412618
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.
NHS North Bristol NHS Trust Trust Headquarters Southmead Hospital Bristol Southmead Road Westbury-on-Trym Bristol 09 August 2018 BS10 5NB Tel: 0117 41 43816 Website: http:/Awww.nbt.nhs.uk FAO: HM Senior Coroner, Ms Katy Skerrett Gloucestershire Coroner’s Court Corinium Avenue Barnwood Gloucester GL4 3DJ Re: Regulation 28 Report to Prevent Further Deaths - The late Mr Robert Andrew Power. | am writing in response to your letter dated 10'" July 2018. Thank you for acknowledging receipt of information already provided by the Trust dated 18" May 2018. The information provided confirms the Trust is now working under different systems than in 2008 and that processes have been introduced to arrange follow-up appointments and monitor and manage a patient on an allocated pathway. Following review of the information provided, | can confirm that the Trust does not have any additional submissions that would assist the Coroner further in this case. Yours sincerely Andrea Young Chief Executive cc:- NBT Legal Services Michele Romaine A University of Bristol Teaching Trust Andrea Young Chair A University of the West of England Teaching Trust Chief Executive
See every Prevention of Future Deaths report matching North Bristol NHS Trust, 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.