Prevention of Future Deaths reports · 2019
Regulation 28 report to prevent future deaths, reference 2019-0401, written 25 Nov 2019. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 25 Nov 2019 |
|---|---|
| Reference | 2019-0401 |
| Deceased | Thomas Browne |
| Coroner | David Regan |
| Coroner area | South Wales Central |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths · Wales prevention of future deaths reports (2019 onwards) |
| Source | judiciary.uk record · original PDF |
| Responses published | none published |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
ANNEX A
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:
The Chief Executive of the Cwm Taf University Health Board
1 CORONER
I am David Regan, Assistant Coroner, for the Coroner area of South Wales
Central
2 CORONER’S LEGAL POWERS
I 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
A Coronial investigation was commenced on 20th July 2018 into the death of
Thomas William Browne. The Investigation concluded at the end of the
inquest which I conducted on 25th November 2019. The conclusion was that
the death occurred as a result of natural causes and the medical cause of death
was 1 (a) Chronic Obstructive Airway Disease; 1(b) Corpulmonale; 2
Hypertension; Previous Myocardial Infarction
4 CIRCUMSTANCES OF THE DEATH
These were recorded as :-
Thomas William Browne, known as “Bill”, was found in a collapsed state in a
toilet at ward 12, Prince Charles Hospital, Merthyr Tydfil at about 12.45 pm on
17th July 2018. He had been taken to the toilet by a nurse and left
unaccompanied. His Oxygen supply cylinder was found exhausted when he was
found.
The Inquest focused upon:-
1
a. The fact that Mr Browne was a highly vulnerable patient reliant upon
non-invasive ventilation by Oxygen
b. He was taken to the lavatory by a member of nursing staff, using an
Oxygen Cylinder said to have been found by her by his bedside.
c. The Nurse left him unaccompanied in the lavatory, did not inform any
other member of staff that she had done so, and left the ward.
d. Mr Browne was found in a collapsed state in the lavatory
approximately 45 minutes later
e. His Oxygen supply was exhausted when he was found.
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. –
(1) Although on the evidence at the Inquest, a finding was made that Mr
Browne died from natural causes, the evidence gives rise to the concern
that patients may be left unaccompanied while being dependent upon a
finite supply of Oxygen, where no systems are in place for ensuring
that they are monitored and assisted before such supplies run out.
(2) The root cause analysis was accepted in evidence by the Trust to be
deficient in that it did not identify and address this issue.
(3) Training in the administration of Oxygen remains incomplete.
(4) There are no formal procedures for recording the time that the finite
supply of Oxygen to patients will expire.
6 ACTION SHOULD BE TAKEN
In my opinion 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 24th January 2020. I, the Coroner, may extend the period.
2
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
I have sent a copy of my report to family who may find it useful or of interest.
HeaIth Inspectorate Wales, Welsh Government, Medical Director of Cwm Taf
University Health Board.
I 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
25th November 2020 SIGNED:
D Regan
Assistant Coroner
(Electronic signature)
3
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