Prevention of Future Deaths reports · 2019
Regulation 28 report to prevent future deaths, reference 2019-0058, written 20 Feb 2019. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 20 Feb 2019 |
|---|---|
| Reference | 2019-0058 |
| Deceased | Kevin Miles |
| Coroner | Dianne Hockling |
| Coroner area | Leicester City and South Leicestershire |
| Category | Other related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
REGULATION 28: REPORT TO PREVENT FUTURE DEATHS (2) REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: 1. Judith Tetlow, Chief Inspector of Diving. Health and Safety Executive 1 CORONER am Mrs Dianne Hocking, Assistant Coroner, for the coroner area of Leicester City and South Leicestershire 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 On 09 November 2018 I commenced an investigation into the death of Kevin Robert Miles aged 70 years. The investigation has not yet concluded and the inquest has not yet been heard. 4 CIRCUMSTANCES OF THE DEATH Mr Miles was undertaking a `re-breather' course with an instructor and was diving at Stoney Cove, Stoney Stanton in Leicestershire on the 25`h September 2018 when his instructor noticed that something was wrong with Mr Miles. They made an emergency ascent to the surface and attracted the attention of centre staff who immediately pulled Mr Miles out of the water and called the emergency services. Unfortunately, after resuscitation attempts failed, Mr Miles was declared deceased at the scene. Mr Miles was an experienced diver and had been diving since about 1992. Mr Miles had previously been investigated by (Consultant Cardiologist) for symptoms of immersion pulmonary oedema due to a dive in 2015 having been cut short when Mr Miles experienced breathing difficulties and the conclusion was that told Mr Miles (confirmed in a letter to Mr Miles' GP dated 27/12/2017) that he should not dive again, not only for the sake of his safety but also for the sake of the safety of any rescuer. The cause of death of Mr Miles has been returned by Office Registered Forensic Pathologist) as:- (Home 1a) Unascertained 5 CORONER'S CONCERNS During the course of the investigation my inquiries revealed matters giving rise to concern. In my opinion there is a risk that future deaths will occur unless action is taken. I n the circumstances it is my statutory duty to report to you. The MATTERS OF CONCERN are as follows. — An Occupational Health Physician, who is also a UK Sport Diving Medical Referee and an HSE Approved Medical Examiner of Divers certified Mr Miles as fit to dive for two years on the 30 January 2018 based on the information given to her by Mr Miles himself in the medical questionnaire and on her physical examination of him. There is currently no re uirement to obtain the diver's General Practitioner records which are often a 'hub' of various information regarding treatment by both hospital and/or private clinic) or otherwise personally enquire into treatment or advice given by any other medical practitioner. In my opinion this system is open for misreporting of health problems or, in fact, failing to report them at all. If there had been a requirement to obtain Mr Miles GP records it would have been quite clear that he had been advised that he should not dive again and presumably the certificate would not have been granted. M y concerns are that not only may divers be risking their own lives by not disclosing salient health facts (that is at their own risk) but that they are also putting the lives of potential rescuers/dive buddies at risk as well. 6 ACTION SHOULD BE TAKEN In my opinion urgent action should be taken to prevent future deaths and I 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 17 April 2019. 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 have sent a copy of my report to the following Interested Persons 1. 2. 3. —partner of the deceased —daughter of the deceased of Clyde & Co —representatives of 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. 9 [DATE] / [SIGNED BY 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.
Lanthwaite Crosscanonby iVlaryport 10July 2019 Dear Sir, am replying to your Regulation 28 request in my capacity as secretary to the UK Diving Medical Committee.We are a voluntary group of experienced doctors who specialise in diving medicine.We meet regularly and advise the sport diving training organisations on medical matters.We also help with medical education to do with diving medicine.We are also consulted by the Health and safety executive on diving matters.We have no office or staff hence this reply isfrom my home address. As a committee,we have had a lengthy discussion about the points raised by .We were all agreed that in an ideal scenario all divers or potential divers should bring copies of a full and none adjusted medical record to all consultations.However wealready have a situation where our hard pressed general Practitioner collegues are refusing to sign or even fill in any forms which are none NHS work. At present,any diving referee[doctor with extra training in diving medicine who is approached by a diver who declares a problem on the current self certification form,can ask them to provide further medical information prior to seeing them.The self certification process was brought in for sport divers in 1999 after a review ofthe previous system of regular medical examinations wasshown to have a very low pick up of problems.The form is reviewed and altered if necessary every 2~3 years. The system requires complete honesty on behalf ofthe diver and the onus is on the diver to provide any corroborative medical information that is asked for.lf the referee is uncertain with what is presented,we have an online forum wherewith the divers consent,we can get help from cotlegues fairly quickly to allow us to proceed in our assessment. Currently the Civil Aviation Authority accepts the applicants declaration about eye tests and vision and the DVLA accepts the applicants word regarding epileptic convulsions and regaining a driving license without resorting to gp notes. We feel as a committee,that at the present time,vve see no reason to change the current system. fours Faithfully • Ffion secretary to UKDMC
See every Prevention of Future Deaths report matching Dianne Hockling, 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.