Prevention of Future Deaths reports · 2019
Regulation 28 report to prevent future deaths, reference 2019-0410, written 28 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 | 28 Nov 2019 |
|---|---|
| Reference | 2019-0410 |
| Deceased | Christina Lawal |
| Coroner | Sarah Bourke |
| Coroner area | London Innner (North) |
| Category | Care Home Health related deaths |
| 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.
Coroner ME Hassell
HM Senior Coroner
Inner North London
REGULATION 28: REPORT TO PREVENT FUTURE DEATHS
THIS REPORT IS BEING SENT TO:
Service Director
Creative Support Ltd
Wellington House
131 Wellington Road South
Stockport
SK1 3TS
1
CORONER
I am: Assistant Coroner Sarah Bourke
Inner North London
Poplar Coroner’s Court
127 Poplar High Street
London
E14 0AE
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
On 30 January 2019, Senior Coroner Mary Hassell commenced an investigation
into the death of Christina Lawal aged 63 years. The investigation concluded at
the end of the inquest which was conducted by me on 7 November 2019.
The conclusion of the inquest was that Miss Lawal’s death was due to natural
causes.
The medical cause of death was:
1a acute myocardial infarction
1b coronary artery atherosclerosis
2 Type 2 diabetes mellitus
My short form conclusion was that “Miss Lawal had a myocardial infarction at
her home on 23 January 2019. The infarction atypically presented as abdominal
pain in the period before she went into cardiac arrest”.
4
CIRCUMSTANCES OF THE DEATH
Christina Lawal had type 2 diabetes with serious complications. She lived in
Duncan Court which is an extra care sheltered housing scheme. She was a
wheelchair user. She attended hospital for dialysis 3 times per week. On 23
January 2019, Ms Lawal attended dialysis and returned home around 6.30 pm.
She informed staff that she was tired and that she was going to bed. At 7.20 pm
she complained of stomach pain. Staff offered to call her an ambulance, Miss
Lawal said that she would speak to the out of hours doctor. Miss Lawal spoke to
the out of hours GP service and was advised to take Gaviscon. She was then left
alone. At around 9.15 pm, Miss Lawal pulled the alarm cord in her flat. 2 staff
members attended to find that she was vomiting and complaining of severe
abdominal pain. One staff member returned to the office in order to make a
999 call to paramedics whilst the other remained with Miss Lawal. Miss Lawal’s
pain increased which led to a further call being made to the ambulance service.
Paramedics arrived shortly before 10 pm. Miss Lawal went into cardiac arrest
shortly after their arrival. Attempts were made to resuscitate Miss Lawal using
advanced life support measures. She was taken to the Royal London Hospital
where her death was confirmed at 23.05.
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 could 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) The care worker had to return to the main office at Duncan Court in
order to make a 999 call as there was no cordless telephone available for
her use.
2) The emergency triage system used by the London Ambulance Service
often involves the caller being asked to give information regarding the
patient’s appearance (e.g. do they feel hot, are they sweating or clammy
etc). Similarly callers may be asked to put questions to the patient
regarding the nature and location pain. A caller may not give the correct
information if they are not with the patient at the time of the call.
3) Callers to the ambulance service may not be aware of further
deterioration in a patient’s condition if they are calling from a different
location.
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 23 January 2020. 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
I have sent a copy of my report to the Chief Coroner and to the following
Interested Persons
(niece)
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.
Sarah Bourke
Assistant Coroner
28 November 2019
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