Prevention of Future Deaths reports · 2018

Karl Cassimjee

Regulation 28 report to prevent future deaths, reference 2018-0339, written 2 Nov 2018. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.

Date of report2 Nov 2018
Reference2018-0339
DeceasedKarl Cassimjee
CoronerTimothy Brennand
Coroner areaManchester (West)
CategoryHospital Death (Clinical Procedures and medical management) related deaths · Mental Health related deaths
Sourcejudiciary.uk record · original PDF
Responses publishednone published

The report

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.

ysniig Aq peuleyep sem peseacep ou} “gTOz Aenuef ISTE OU UO “pb

*JOISOYIUL| 0} PAO pasesdap ayy ‘ZTOZ Jaquua}das
STZ 9y) UO abueyssip Bulmoyjoy ‘aulyseyD ‘jeydsoH abpuquaye|D
32 PseM Pjayeye7 9yj uo uolsswWpe yuajedul aAjoAu! 0} SEM 3eU}
ales pue Juawjea.} Joy weal je]UaW AyuNUWOD Ja]seaYyD 243 0} paueyes
Sem /T0Z JsNBny UOT 34) UO pue asdejas yJeaY jeJUaLW e palayns 3H “E

quawAojdwea
Burjaas WopBbuly payup au) Ul paAjue pesearap oui ‘ZTOZ IsNBny ul “Zz

*AJBAPAIaSUOD UapaMs ul AQUOS j
awoy siy ul pebeuew pue pajea.y uaaq pey ey) seposida dnoYDAsd
UM elusiydoziUuds ploueied paunsaid jo Aiojsiy e pey paseasap OYyL ‘T

HLV4d 4HL JO SAONVLSWNOUID b

*,UJ2ap [equApIIIe,, JO UOISN|9UOD WO LOYs e Sem YSanbUT auy Jo UOISNjDUOD SUL

e1uWuayyodAH "eT
‘SPM UJeAap JO asned jedIPSwW ayL

“ST0Z
4390730 ZT BY} UO Jsanbu] ay jo pud ay] ye papnjouod uONeBNSSAUT UI “Z86T
Alenigad wz UO U1og ‘suead O¢ pabe ‘aafuisse> ysewWjobuZ wejnor |!WweL Jojo
Wey JO uJeap auy OUI UONeBASAEAUT pUe paeduUBLWOD I gTOZ Asemigay wéZ ay) UO

AISANONI Pue NOLLVDILSSANI | €

“ETOZ
suoneinBey (suonebassaul) siau0s0D ayy JO 6Z pue gz suonejnBas pue 6007 PY
a0NsNeC pue siaUdJOD 3y} Jo ‘¢ ainpauds ‘72 YdesBe1ed sopun yoda siuj ayew J

SUAMOd 1V937 S,MANOUOD |<

359M JaysoyoueW
JO Bduly 4BU0IOD aL JOJ “480105 JueNsIssy ‘pueUUaig AA AUJOWULL Wwe J

YANOUOD | T
M6 ETW JaIsaysue~ ‘peoy piojxo ‘Aewuyuy jeAoy
daysayouep] ‘wed, uosiely yyeeH |eUSW “9beue) ae 7~
TAE SZW ‘YdIMysoud ‘peoy MeN Aing ‘Jsn4) UORepuNoJ
SHN UE9H [ee] JoJsaypueP] Jayeasd “AQNOaXY JoIUD ‘AYEMUL IPN AW *T

‘OL LNAS ONIAG SI LYOd3ae SIHL

SHLV3d 3YNLN4A LNAAIUd OL LYOdaY SZ NOLLVINOAY

‘}SANDU Ul ABYJE PSN 9G 0} Sf ULIOJ SILL “LON

(T) SHLV4d SUN.LNI LNAAIUd OL LUOdTY °8Z NOLLVINDIY

‘JeU) pseay sem aduapIAa ‘sonbuy ay) Bung “T
UsJa9U09 JO Sa} JO S2dUe}SWINID Jag

:SMO||OJ S2 212 NYADNOD 4O SYALLVW SUL

"nod 0} YWodas 0) Ainp Auoynje3s Au SI 1 SaDUe}SWINIID ALY UT “W923 SI
UoNDe ssaUN 1ND90 ||IM SUJeSp aangny yeyI YS e SI s4auy UOIUIdO AWW UT ‘UtaDL09
0) asi BulAIB suayew pajeanas ouaptAd ay} Jsanbul 33 Jo asuno>d ayy Hung

“paip pue ujeua} Appnu ul pesde)jo> pue sainjesaduua} Buizoa.y
Buyieaoid ayy JO souaNbasuod e se ejualyodAY 0} paquundons pue YM
Jeyiwey JOU SeM ay eae Ue Ul ISO] aLUOIaq PeY Pue jeuOIsNjap ‘2noYsAsd
SPM peseasap ay} Jey) paye!sUOWAap aoUAapIAS auy ‘gTOZ Aleniqedy

WS pue puz ayy UaaMjeq Useq pel] paseedap a4} 394M Ule|dxa

0} SUSPIAS OU SEM aJ9U} ISIIUAA ‘BUGIS BU} Je peap WI pedunouo.d
SoIpaweseg "U0IOg ‘UOINH 48AQ ‘anuaay Jayemabplg ‘Z Wun Jesu

splay uado 0} Juaselpe sapiyen Aneay Aq dn pauiny> usaq pey pue] ayy
DJYM Sys elysnpu! Aresoduia} ayowWeJ-jWas e UI UON|PUOD sAIsUodsasuN
‘pasde|joo e ul pasaAoosip sem Apog Siy gTOZ Aleniqeag »S 2U3 UO ‘OT

“JUURLU 8.URZIG pue Jeune! ue U! Bude YS|IYM Ja]sayueW
BIO} UOWIH BUp 3 STOZ Alenuqe4 puz aUQ UO BAe UBaS Se] SEM
paseadap ay) eu} paysijqeysa UOHeHNSaAU! eo! Ja}sayoUeW Ja}eaIN V “6

*gT0z Aleniqed .€ 34) UO Bulssiw se paseadap ay] paliodad | IHHW 8UL *8

"TOZ Aleniqes $8 wb ‘wE ‘2 OU) UO palisIA susuOnHIeId
LLHHW 8ug UayM ssauppe awoY sly 32 JOU Sem paseadap ayL ‘2

‘Adas Jo asuodsai OU Ul paynses YUM gTOZ Alensqe, IST 84} UO
aaeid 400} yr1yum auoydajay Aq Ze\UOD paldwaye JauonNIe/d LLHHWV 9

‘Adwia aq 0} paseadde ‘joe ul ssouppe ay “ssezppe

3uy JO siaidno90 YM epew sem Aynbua 40 49849 JaUJO ON “apes pue

UMOP WIE? PjNOMm ay 3ey) adoy au} Ul Ssaippe ay} Je pesearap au} BARD]

0} UOISPAp 34} YOO) ‘AreWUYUT jeAOY Ja}seyUeW By} Je JUeWSsasse

Sly 0} Jol UONIPUOD pavtasqo sly UeL] as10M OU Buleq ‘paseasep

BU} PaUNsse Suad1YO aad Podsued) YsUg ‘passa.ysip pue payee
awed9q pasearap au} ‘sseippe aWOY SIYy 0} pasealjep Buiaq uody, *¢

ye aouapises siy
0} Wily peuinjas aoljod pue (LLHHW Jeyeeiey) wee] quowjees, SWo}H
UJeaH [eUaW 24) UM JUBWAabebue JayyNy Buinbas se pasoubelp

pue Jensibay Ageiysssg e Aq passasse sem ay *ABWIUT [eAoY
Jayseyouep 0} Udye} pue ESET Py YINESH [e}UaW BY} JO 9ET UONDES

| _ JO Suolsivosd ayy Japun ones Aempey Ajipecdid 32 20110 WodsuesL

‘pause 40 aoejd ul jnd uaeq jOU aAeY MatAas pue
UOISIADJ JO pasu U] SB peyNuap! swa}sAs jeuoesado ay) ‘ayep OL ‘|

sJeY) PAWUYUOD JSanbuT ye periadad adUapIAa 9U} “IOABMOH

‘ssaooid ,Bupjew uoisiap,, ay) ul sauONQIeId Yons je BulAjoAut
Buipnpur ‘sjod0}01d pue swaysAs Buysixe 0} aouaJaype pue Guides,
pode. saosduut 0} sdauOnNDe!d UOSsIe!) YeaY jeWUaLW 0} JapUIWa! y ‘dD

tased yons ul Ajdde pue yseye
0} yoeoidde epuabe wea, Areuljdinsig AINW PasiAel e 40) pseu sul "q

‘pasiaat aq 0} ainpesoid
jeuonesedo wea) uyeaH [eUaW AjUNUWOD au) JoJ paeu ay, “2

spaynuap! AQde209 yey) Yoda MalAay JUEPINUT SA|suaYyesdWOd
& paynpuod pey Isn4y YYyeay (equa, JeyseyoueW Ja}e015 BUA IS|IUM

fyun020e OJ! Uaye} Bq 0} SUIBDU0D

SaSJNU a4 JO} soeid Ul saINpadoid jeUOeIado ayy UIUIM SUBS

ou Bulag a1ay} — UOQUaJep PY YI eaH [e}Ua,) PUSWIWOIOI 0} J UBS OU
pey sensibay ayy eu) asiduns eula.yxe passeidxa asinu aug Jey) JUaIXe
ayy 0} WeNsIBay Ayelnads ayy Aq payenjeaa ALadoud 40 Ajayenbape
‘AINy Usaq BABY 0} Was JOU Op 7eUy syeljeq Plouesed jeuoisnjap

POY Sly Jo JUAYXe |/NY ayy Jno BuMes paseacap ayy Aq Jay 07 UDdAIB
Alojsiy pallej@p pue jejueysqns e pple. pey asJNN YESH [EUAW V

‘wa\u! BY} U! UONeJOLEyep

@ JO JUDAS JU} U! UAYe} dq 0} UNDE JEYM JO LHHW 24} YIM eIUOD
ynoge (ewoy siy 0 yoeq paseasap 34} Bune} AjjerisAyd Jo Ayyiqisuodsas
dU) YIM Payse} a4aM OYM) 9dI/0d Wodsuel Ys ey) Jo/pue
paseacap au} UONeWWOJU! JeUM 0} Se spiodaJ JUaed WOd JeSsjOUN SI IT

“weal

quawjeals) SWOH UJeEaH |eqUeW ayy Aq Uaas Bulag 0} abseyosIp Woy
UONIPUODS SIY U] UONBJOLajJap e& JO JUBAa 9UQ Ul Bye} PjNod ay sainseou
JeYM 0} Se a2d!APe paAlade. paseadap au} ye) aIUAaPIAD Jea/9 ‘Aes

0} S| }2U}) pasearap oy} UM BulUUe|d Ayes aAQesOgeE||OD JO B2UapPIAa
OU PU JSII JO UONE|NWUOY 4e9]9 OU SEY JUBLUSSASSe YSLI SU] JO P4094 SUL

yewiydo
-qns aq 0} paydeoce sem JejnsiBay ayy Aq papsooed se ‘“JusWSsasse aU)

auonAIe!d YYeay |eEyUeW perosdde ZT UONIES puodas ay} WO. WIOY
Axjua Bupoddns ou UjIM JeULOs aU0IU! ayy Ul WaysAs ,soBiwy,, at)
uo paaqua sem JensiBay ysyelnads ay) Aq payajdwos juawssasse eyL

{(jeudsoH ebpuqueye|D Bupnpul) paweyqo Bulag Aloysiy
[2.18)2||02 B jnoUM paye|dwios useq pey yuaussasse Py UIJEdSH [EUEW V

pueuusig MM AyjounL stoc Tr'zo
h

= 5)
ne Sa prea
*sJQUOIOD JalyD ayy Aq asuCdsa. ANOA jo

uoljesiqnd ayy 40 aseajas ayy ynoge ‘asuodse unoA Jo au 9UQ Ye ‘49U0IOD 9}
‘a 0} suoneyUasaidas ayewu AewW NOA *3SasajUI JO 40 jnJasn W Puy Aew sadatjaq

ay oym uosuad Aue 0} Yoda siuj Jo Adoo e puas Aew aH *wuoy AsetuLuns
40 papepal Jo ajajdwod e ul UO 410 JaUye Ysyqnd AewW JAUOLOD JalyD SUL

‘asuodsas snoA jo Adod 2 J8U0JOD JalyD BY puas 0} Ajnp e sapuN osje we T
*ADd1JOq Ja}SAyUeW) 19}e319 pue Vd1|\0d

yiodsuel) Usiig ‘paseazap au) Jo JaujoW ee ee paysaaqul
Buimoj|oJ ay} 0} pue J9UOIOD Jaly> auj 0} Woda Aw jo Adod e Juas aney J

NOLLVOT19Nd pue saIdOD

*pasodoud s!

uonoe ou Am ulejdxa ysnu NoA asWUsy{O *UONDe J0J ajqeyeWA ayy Jno Hunjas
‘uaye} aq 0} pasodoid 10 uaye] UONDe JO Sjleyap UJe}UOD JsnW asuOdsa JNO,

“poled ay) puayxe Ae “JU0I09 BY} “T “STOZ Jaquiaced /Z Aq Ajaweu “Wodas
Siu) JO ayep auQ Jo SAep 9g UILIM Yoda si] 0} puodsai 0} Ajnp e Japun ae No,

3SNOdS3u UNOA

“uooe YoNs 342} 0} Jamod ay} saey suOes}UeBIO ANCA pue NOA aaaijaq
J pue sujeap aingny juadasd 0} uaye} aq Pinoys UORIe Juabun UO!UIdO AW UT

NayVL 3d GINOHS NOLLIV

uaned au] JO UOnIPUOD ayy UI UONeJOLa\ap

@ JO JUSAA BY) Ul 10 ‘JOU SI YJ] aye} 0} UODe JeYM 0} Se UONDN.ASU!

pue ajetdoidde s} ,awoy,, au} Jey} ainsue 0} UOAINYsU! ayenbape s}

244} Jeu} , AWOY,, 07 aBseyosip jeqidsoy woy JuaVed ayy jo Jaysuety
dU} Ul PAaAJOAU! aUOIEq SAY AdUabe JaYYO JO BdIjOd ayy B4BUAA “q

‘speeu pue uoIpuco Hunuaseid s,paseadep au} YM juaned
@ 40y asodund 40J Jy Se ajqeqins se pawyUod pue paylea uaaq sey
ssauppe , awoy,, dy} Jey] — dn MO|[OJ 1 LHHW UM aBueyssip e uody ‘e

:Ajaueu
‘posapIsuod Udaq JOU Sey ased yUeYsU! ay yo Bujes| Dyjoads aU ‘|

Related reports

Other reports by Timothy Brennand

See all →

More reports categorised “Hospital Death (Clinical Procedures and medical management) related deaths”

See all →

Track Hospital Death (Clinical Procedures and medical management) related deaths

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.