Prevention of Future Deaths reports · 2019
Regulation 28 report to prevent future deaths, reference 2019-0130, written 5 Apr 2019. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 5 Apr 2019 |
|---|---|
| Reference | 2019-0130 |
| Deceased | Yong Hong |
| Coroner | Sonia Hayes |
| Coroner area | South London |
| Category | Care Home Health related deaths · Community health care |
| 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 (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. Bondcare , Clarendon Care Home 2. Thornton Heath medical Practice GP 3. Croydon County Council ~ Adult Soclal Care, Immigration & Asylum 4. Care Quality Commission CORONER lam Sonia Hayes, assistant Coroner, for the coroner area of South London 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. INVESTIGATION and INQUEST On 18" July 2017 an investigation was commenced into the death of Yong Kang Hong age 60. The investigation concluded at the end of the inquest on 10" August 2018. The Conclusion of the inquest was the medical cause of death being 4a Hypoxic Brain Injury 1b Cardiac Arrest (resuscitated) 1¢ Suspension (Clinical) and the Conclusion Suicide (contributed to by neglect) CIRCUMSTANCES OF THE DEATH An asylum seeker with very little English was transferred from hospital to a care home. Displayed self-harm and suicidal behaviour including attempting to strangle himself with his call bell, this was removed. On 5° July the GP was significantly concamed about his suicidal behaviour to make an immediate referral to mental health services and advised constant observations. He could not communicate with staff and no interpreter was sought. His call bell was returned to him, no risk assessment was conducted and no further Input from the GP was sought. His cail bell was returned to him and en the moming of 12" July he used It to hang himself from the curtain rail in his bedroom. CORONER'S CONCERNS During the course of the inquest the evidence revealed matters giving rise to concer. 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) His GP made an immediate referral to mental health services and advised constant observations, however: (a) the observation regime advised by the GP was not implemented (b) whitst awaiting a formal review of his mental state, no interpreter was sought in the meantime to assist with assessment of his needs due to Issues of confusion between the social work team and the care home about responsibility for funding (c) no risk assessment was carried out prior to making the decision to return his call bell. (2) No further advice was sought from the GP or other €ppropriate clinician and he was left in social isolation without any means fo express his distress, no safety net and no therapeutic engagement (3) Evidence at the inquest was that care home staff did not receive training in how to carry out risk assessments ACTION SHOULD BE TAKEN In my opinion, action should be taken to pravent future deaths and | believe you and your organisation 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 28" April 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 ae ca Clarendon Care Home, Thornton Heath Medical Practica GP Croydon County Council and the Care Quality Commission. 1am algo 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. ° | Sonia Hayes
for Plymouth Torbay and South Devon REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: Medical Director, Derriford Hospital Trust CORONER lan Arrow, Senior Coroner, Plymouth Torbay and South Devon 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. http://www. legislation.gov.uk/ukpga/2009/25/schedule/5/paragraph/7 http://www. legislation.gov.uk/uksi/2013/1629/part/7/made 3 INVESTIGATION and INQUEST At an Inquest hearing at Coroner’s Court, Derriford Park, Plymouth on the 17 day of April 2019 heard before lan Michael ARROW, Senior Coroner, the following findings and determinations were made: Name of the deceased: Roger Albert NEAVES Medical Cause of Death: la Sepsis 1b Pneumonia 1c Fractured Neck of Femur (left) i} Parkinson Disease The Coroner recorded his conclusion as Accident 4 CIRCUMSTANCES OF THE DEATH The deceased fell in his bedroom on 16 October 2018. He fractured his left femur. He was conveyed to hospital. He deteriorated and died on 18 October 2018. 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 Coroner received evidence from FY the author of a Root Cause Analysis conducted by the Hospital Trust following Mr Neaves’s death. That Root Cause Analysis made various recommendations which required action by the Hospital Trust. The Coroner is concerned to receive confirmation that the recommendations have been fulfilled. ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and | believe you as Medical Director have the power to take such action to ensure the recommendations are fulfilled. YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 13 June 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. COPIES and PUBLICATION | have sent a copy of my report to the Chief Coroner and oii” wife of the deceased, at her home address. | 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 ygur response by the Chief Coroner. Dated 18 April 2019 | M ARROW, Senior Coroner
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