Prevention of Future Deaths reports · 2018
Regulation 28 report to prevent future deaths, reference 2018-0234, written 19 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 | 19 Jul 2018 |
|---|---|
| Reference | 2018-0234 |
| Deceased | Ronald Harman |
| Coroner | Veronica Hamilton-Deeley |
| Coroner area | Brighton & Hove |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| Organisation named | Brighton and Sussex University Hospitals NHS Trust |
| 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.
THE CORONER’S OFFICE WOODVALE, LEWES ROAD BRIGHTON BN2 3QB VERONICA HAMILTON-DEELEY DL, LL.B. Her Majesty’s Senior Coroner for the City of Brighton & Hove Telephone: Brighton (01273) 292046 Fax: Brighton (01273) 292047 Assistant Coroners CATHARINE PALMER LL.B (HONS) KAREN HENDERSON, BSC,BM,MRCPI,FRC. . GILVA D.J.TISSHAW, BA(LAW)HONS CORONERS SOCIETY OF ENGLAND AND WALES ANNEX A REGULATION 28: REPORT TO PREVENT FUTURE DEATHS (1) NOTE: This form is to be used after an inquest. THIS REPORT IS BEING SENT TO: 1. Dr Rob Haigh, Medical Director, BSUH 2. Dr Stephen Drage, Deputy Medical Director and Safety and Quality Consultant in Intensive Care and Anaesthetics, BSUH Ms Marianne Griffiths, Chief Executive, Brighton & Sussex University i S Trust Chief Nurse BSUH Matron for Old People Ward Manager for Level 8A bad 4 CORONER | am Veronica HAMILTON-DEELEY, Senior Coroner, for the City of Brighton and Hove : 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 16" March 2018 | commenced an investigation into the death of Ronald Thomas HARMAN. The investigation concluded at the end of the inquest on17TH July 2018 .The conclusion of the inquest was NARRATIVE CONCLUSION. 4 CIRCUMSTANCES OF THE DEATH See Record of Inquest (See attached sheets) 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 VERONICA HAMILTON-DEELEY DL, LL.B. Her Majesty’s Senior Coroner for the City of Brighton & Hove THE CORONER’S OFFICE WOODVALE, LEWES ROAD BRIGHTON BN2 3QB Assistant Coroners CATHARINE PALMER LL.B (HONS) : KAREN HENDERSON, BSC,BM,MRCPI,FRC.- GILVA D.J.TISSHAW, BA(LAW)HONS Telephone: Brighton (01273) 292046 Fax: Brighton (01273) 292047 taken. In the circumstances it is my statutory duty to report to you. The MATTERS OF CONCERN are as follows: — (1) Brighton & Sussex University Hospitals NHS Trust’s Transfer Policy once again ignored. (2) No transfer should take place unless and until it is adhered to. (3) Care at Newhaven Downs suboptimal. Patient deteriorated Returned to Royal Sussex County Hospital with aspiration pneumonia. Died of aspiration pneumonia (unable to respond to/benefit from anti biotics) 8 days later. 6 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. 7 YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 10" October 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. 8 COPIES and PUBLICATION | have sent a copy of my report to the Chief Coroner and to the following Interested Persons 1. HE Daughter of Mr Harman 2. EE Brighton and Hove CCG 3. Secretary of State for Health, Department of Health 4. Simon Stevens, Chief Executive, NHS England 5. David Behan, Chief Executive, CQC | am also under a duty to send the Chief Coroner a copy of your response. VERONICA HAMILTON-DEELEY DL, LL.B. Her Majesty’s Senior Coroner for the City of Brighton & Hove THE CORONER’S OFFICE WOODVALE, LEWES ROAD BRIGHTON BN2 3QB Assistant Coroners CATHARINE PALMER LL.B (HONS) KAREN HENDERSON, BSC,BM,MRCPIFRC. . GILVA D.J.TISSHAW, BA(LAW)HONS Telephone: Brighton (01273) 292046 Fax: Brighton (01273) 292047 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. 9 Date: 19" July 2018 SIGNED BY: tana hw Ace Senior Coroner Brigh
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