Prevention of Future Deaths reports · 2018
Regulation 28 report to prevent future deaths, reference 2018-0261, written 21 Aug 2018. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 21 Aug 2018 |
|---|---|
| Reference | 2018-0261 |
| Deceased | Louie Bradley |
| Coroner | John Pollard |
| Coroner area | Manchester (West) |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths · Child Death (from 2015) |
| Organisation named | Bolton NHS Foundation Trust |
| Source | judiciary.uk record · original PDF |
| Responses published | 2 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
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. Jackie Bene, Chief Executive, Royal Bolton Hospitals NHS Trust, Minerva Road, Farnworth, Bolton BL4 0JR 2. 1 CORONER I am John S Pollard, Assistant Coroner for the Coroner Area of Manchester West. 2 CORONER’S LEGAL POWERS I 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 31st August 2017 I commenced an investigation into the death of Louie Francis Bradley, aged 1 day. The investigation concluded at the end of the inquest on the 15th August 2018. The conclusion of the inquest was that he died from Sudden and Unexpected Neo-Natal Death of an Infant born at 42 weeks with widespread pneumonia. The narrative conclusion was as follows:- On the 27th August 2017 Louis Francis Bradley died as a result of a combination of Natural Disease (undiagnosed Bronchopneumonia and the symptoms of the common cold) and an accidental obstruction of his airways whilst in bed following a breastfeed. 4 CIRCUMSTANCES OF THE DEATH He died following breast feeding in bed with his mother when mother fell asleep. 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 midwives at your Hospital gave evidence that they still advise breastfeeding in bed whilst lying side-by-side with the baby even if no-one else is present and the mother is obviously fatigued, this leads to 1 inadvertent co-sleeping and as in this case can lead to death. 2. The standard Trust issue documentation was not (properly) completed with the omission of vital information such as mother’s name, GP Practice, address etc.; similarly advice allegedly given to patient was not documented. 6 ACTION SHOULD BE TAKEN In my opinion urgent action should be taken to prevent future deaths and I believe that you 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 17th October 2018. I, 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 I have sent a copy of my report to the Chief Coroner and to the following Interested Persons:- 1. I 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. Dated Signed 21st August 2018 John S Pollard HM Assistant Coroner, Manchester West 2
2 responses 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.
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Telephone: (01204) 390390 ext 5912 NHS | Our Ref: 1.002245 Your Ref: JSP/YD/2815-2017 Bolton NHS Foundation Trust 16 October 2018 Mr J $ Pollard RECEIVED HM Assistant Coroner 22 OCT 2018 Coronial Area of Manchester West Paderborn House, Civic Centre BOLTON BL1 1JW Dear Mr Pollard Re: Louie Francis Bradley Re: Regulation 28 Report to Prevent Future Deaths | am writing in response to your Regulation 28 Report to Prevent Future Deaths, issued following the Inquest touching the death of Louis Francis Bradley on 15 August 2018. May | take this opportunity to extend my deepest sympathy to Mr & Mrs Bradley for their loss and appreciate this will remain a very difficult time for them and their family. | am now in a position to respond to your concerns as outlined in Section 5 of your report. Section 5 (1) and (2) | am aware that during the course of establishing how Louise came about his death you raised concerns about mothers choosing to bed share with their babies while breastfeeding. Following receipt of the Regulation 28 Report, | requested that the Head of Midwifery/Divisional Nurse Director and the Governance Lead for the Families Division review your concerns and would like to assure you that further actions in addition to the actions identified in the Serious Incident Report have been taken. | have attached an Action Plan which details a number of improvements together with the relevant documentation which is in now place for your reference. | hope that my response has provided you and the family with the assurance that the Trust has taken appropriate action regarding safe sleeping advice and documentation. Please do not hesitate to contact me in the event you require any further assistance Yours T. & Dr Jackie Bene Chief Executive Encl. Action Plan with supporting documentation
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