Prevention of Future Deaths reports · 2018
Regulation 28 report to prevent future deaths, reference 2018-0407, written 27 Dec 2018. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 27 Dec 2018 |
|---|---|
| Reference | 2018-0407 |
| Deceased | Kenneth Bardsley |
| Coroner | Alison Mutch |
| Coroner area | Manchester South |
| Category | Product related deaths |
| 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.
REGULATION 28: REPORT TO PREVENT FUTURE DEATHS
REGULATION 28 REPORT TO PREVENT FUTURE DEATHS
THIS REPORT IS BEING SENT TO: Care Quality Commission,
Registered Manager of Serendipity Care Home, Chief Executive of Lancs
& Cumbria Lifts UK Ltd, Chief Executive of Health and Safety Executive,
Secretary of State for Work and Pensions
{1 | CORONER
| am Alison Mutch, Senior Coroner, for the Coroner area of South
Manchester i
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 1° February 2017 | commenced an investigation into the death of
Kenneth Roy Bardsley. The jury inquest concluded on the 26th November
2018 and the conclusion of the jury was one of Accidental death
contributed to by failure of interior door mechanism.
The medical cause of death was 1a) Multiple injuries; 2) Osteoporosis;
Ischaemic heart disease; Valvular heart disease
4 | Mr Kenneth Roy Bardsley died on the 30th January 2017, at Salford
Royal Hospital due to multiple injuries, received as a passenger in a lift,
which malfunctioned at Serendipity Care Home.
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. —
. The inquest heard that there are no formal requirements for a
minimum standard of qualification for people to be lift
engineers. In effect, anyone can advertise themselves as a lift
engineer/maintenance company;
2. The evidence given to the inquest was that there was a gap in
the system which meant that regulatory lift examinations could
take place but not be read or acted upon, with no escalation
process;
3. During the inquest evidence was given that within the specific
lift company in this case and more widely, there was a lack of
clarity as to how engineers should be made aware and follow
up requirements made by engineers carrying out the regulatory
lift examinations;
4. In inspections of the home, the CQC did not pick up that there
were faults identified in the regulatory examination that had not
been acted upon;
5. That Serendipity Care Home did not have a system in place to
ensure details from the lift examinations were read; considered
and passed on to the lift servicing company;
6. That the lift company Lancs and Cumbria engineers carrying
out serving/repairs were not expected to ask to see the
regulatory examination reports;
7. That the lift company Lancs and Cumbria Lifts had abandoned
their old paper checklists and introduced an electronic
appointment system. However that system did not include an
electronic checklist. One had now been introduced. It was
unclear if other companies have checklists and if so how
consistent are they. The inquest heard that there was no
statutory minimum expectation about the requirements of a lift
service.
ACTION SHOULD BE TAKEN
In my opinion, action should be taken to prevent future deaths and |
believe you have the power to take such action.
YOUR RESPONSE
You are under a duty to respond to this report within 56 days of the date
of this report, namely by 14" February 2019. |, 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 and to the following
Interested Persons namely 1) , son of the deceased; 2)
3) Bureau Veritas Ltd, who may find it useful or of
interest.
| 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.
Alison Mutch OBE
HM Senior Coroner
27.12.2018
See every Prevention of Future Deaths report matching Product 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.