Prevention of Future Deaths reports · 2018
Regulation 28 report to prevent future deaths, reference 2018-0286, written 12 Sep 2018. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 12 Sep 2018 |
|---|---|
| Reference | 2018-0286 |
| Deceased | Abigail Hall |
| Coroner | David Urpeath |
| Coroner area | South Yorkshire (West) |
| Category | Other related deaths |
| 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.
REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: ger Derwent Students Unit 13 Rani Drive Basford Nottingham NG5 1RF 41 | CORONER | am David Urpeth, assistant coroner, for the coroner area of South Yorkshire West 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 3.12.15, | commenced an investigation into the death of Abigail Hall. The investigation concluded at the end of the inquest on 12.9.18. The conclusion of the inquest was Accidental Death. 4 | CIRCUMSTANCES OF THE DEATH Miss Hall died at home on 23.9.15. She died of 1(a) Aspiration Pneumonitis 1(b) Viral Gastro-enteritis 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. — During the inquest, evidence showed:- There was no defibrillator at the premises nor were Derwent staff first aid trained. This position apparently still persists. 6 | ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and | believe you [AND/OR 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 3.10.18. 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. COPIES and PUBLICATION | have sent a copy of my report to the Chief Coroner to all interested Persons :- Abigail’s parents Sheffield Hallam University a Abigail’s Grandmother -___ | 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 beli may find it useful or of interest. You may make representations to me;the Coroner, at the time r response, about the release or the public: of your response by the Chief Coron —— 12/9118 SIGNE! DAVID URPETH ASSISTANT CORONER
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.
Regulation 28 Report response from Derwent Facilities Management Limited Following the conclusion of the inquest into the death of Ms Abigail Hail, Derwent Facilities Management Limited (Derwent) has received the report from the Coroner dated 12 September 2018 (the Report). The Report was sent to Derwent by the Coroner under paragraph 7, Schedule 5 of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013 and the Report sets out concerns raised by the Coroner in respect of actions that should be taken to prevent future deaths. Ms Hall died at student accommodation managed by Derwent in Sheffield, known as the Trigon (the Premises). The Coroner concluded that Ms Hall's death was an accidental death and made no findings of fact that the presence of a defibrillator at the Premises and/or Derwent's staff at the Premises having had first aid training would have or could have prevented Ms Hall's death. However, the Coroner has raised a concern in the report that there were no defibrillators at the Premises managed by Derwent at the date of the death of Ms Hall and since that date none had been installed. An additional concern of the Coroner was that the employees of Derwent at the Premises were not first aid trained, and no training had been provided since the date of Ms Hall's death. In the Report no specific actions were set out for Derwent to implement. However, since the inquest has concluded, Derwent has made the following changes to their internal training, processes and procedures: 1 Derwent has reviewed its training schedule and a programme of emergency first aid training for staff has commenced. The training is not compulsory. The training that is scheduled to be delivered will be Emergency First Aid at Work. The Course overview is attached to this response as Appendix 1. 2 In respect of the Premises, the following changes have been made: 2/1 Itis anticipated that around 80% of the staff employed to work at the Premises and within the company wilt be completing emergency first aid training. This training is due to commence in December 2018; 2.2 The location and route to the nearest Automated External Defibrillator (AED) has been highlighted within the Premises reception area; 2.3 The purchase and installation of an AED has been approved and this will take place in due course; and 2.4 2 of Derwent's 11 sites already have an AED installed on site. The AEDs have been installed on these sites following the need being highlighted by the completion of a risk assessment. In the circumstances, we consider that the above steps address the Coroner's concerns. ay . Signed: Dated: 23/11/18 THL.134645387.1 1 HVJ 846651
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