Prevention of Future Deaths reports · 2019
Regulation 28 report to prevent future deaths, reference 2019-0220, written 26 Jun 2019. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 26 Jun 2019 |
|---|---|
| Reference | 2019-0220 |
| Deceased | Maureen Martin |
| Coroner | Andrew Haigh |
| Coroner area | Staffordshire (South) |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| Organisation named | University Hospitals of Derby and Burton NHS Foundation Trust |
| 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 !S BEING SENT TO: Gavin Boyle, Chief Executive, University Hospitals of Derby and Burton NHS Foundation Trust, Uttoxeter Road, Derby, DE22 3NE CORONER 1am Mr Andrew Haigh senior coroner for the coroner area of Staffordshire South 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 i On 25 April 2019 | commenced an investigation into the death of Maureen Veronica Martin aged 88 years. The investigation concluded at the end of the inquest on 26 June 2019. The conclusion of the inquest was ‘accident’ with the cause of death being ‘subdural haematoma’. CIRCUMSTANCES OF THE DEATH Maureen Martin was admitted to Queens Hospital on 10" April 2019 with cardiac problems. In the early hours of 14" April, while attempting to mobilise by herself on the ward, she fell and sustained a severe head injury. This was not suitable for surgery and it led to her death at the hospital on 19" April. 6 | ACTION SHOULD BE TAKEN CORONER'S CONCERN During the course of the inquest the evidence revealed matters giving rise to a 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 MATTER OF CONCERN is as follows. — Mrs Martin's family were very pleasant and extremely gracious about the circumstances of her death. Her son pointed out that at the time of her fall, the desk for the Nurses’ Station on the ward was facing the wrong way. Possibly this was linked to some temporary decoration works. When Mrs Martin’s son mentioned this, the desk was repositioned appropriately. | would be grateful if you could check that the desks at Nurses’ Stations in Queens Hospital are properly positioned and, if they do temporarily have to be moved, that the best possible visibility is maintained. In my opinion action should be taken to prevent future deaths and | believe you 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 Monday, 26" August 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. 8 | COPIES and PUBLICATION | have sent a copy of my report to the Chief Coroner and to the following Interested Persons: Mrs Martin’s family - Aviva Life Services UK Limited Scottish Widows Unit Trust Managers Limited | 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. Andrew A Haigh HM Senior Coroner for Staffordshire (South) Coroner's Office No 1 Staffordshire Place Stafford ST16 2LP Tel No: 01785 276127 sscor@staffordshire.gov.uk
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.
NHS University Hospitals of Derby and Burton NHS Foundation Trust LEGAL DEPARTMENT Royal Derby Hospital Uttoxeter Road Mr A A Haigh ; Our Ref: KF/417/MM DERBY HM Senior Coroner for i DE22 3NE Staffordshire (South) POR 01332 340131 Coroner's Jurisdiction E-Mail: Po DX 712320 Stafford 5 Telephone: 12 August 2019 Dear Sir RE: Regulation 28 Report following the inquest touching upon the death of Maureen Martin | am writing in response to your Regulation 28 Report dated 28 March 2019 following the inquest touching upon the death of Maureen Martin. During the inquest | understand the lady’s family raised a concem that at the time of Mrs Martin’s fall on Ward 5, the Nursing Station was facing the wrong way, possibly because there was some temporary decoration works being carried out. Mrs Martin's son highlighted that when this was pointed out to the nursing staff steps were taken to move the nursing station desk to a more appropriate position. You have therefore, quite properly, asked for the Trust to check that the desks at each nursing station in Queen's Hospital are properly positioned and, if they do temporarily have to be moved, that the best possible visibility is maintained. | would like to begin by offering an assurance that the Trust has taken urgent steps to address your concems as follows: 1. Mrs Martin’s fall on Ward 5 was the. subject of an internal investigation which concluded that the nursing station was indeed moved and it was found not to promote visibility of the patients as the nurse, if sat at the station, was facing the incorrect way. The action that arose out of this investigation was to remove the nursing station desk on that Ward and provide the staff with a “desk on wheels” so that this can be wheeled with the staff as they walk around the Bays. www.uhdb.nhs.uk Chairman: John Rivers CBE DL Follow us on Twitter @UHDBTrust Chief Executive: Gavin Boyle 2. A walkaround review has also been undertaken of all of the nursing stations/desks at Queens Hospital Burton to see if they are positioned in the correct places. | would like to assure you that they are all in the correct places and are facing the correct way. Indeed, most of the nursing desks are on wheels to allow nurses to complete their paperwork whilst they are in the Bays caring for patients; this encourages more visibility of the nursing staff and allows more time for the nurses to be with patients. | trust that you will be satisfied and assured that the desks are in the correct places and promote visibility for the safety of our patients. Please do not hesitate to let me know if you require any further information from the Trust. Yours faithfully Gavin Boyle Chief Executive
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