Prevention of Future Deaths reports · 2019
Regulation 28 report to prevent future deaths, reference 2019-0437, written 18 Dec 2019. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 18 Dec 2019 |
|---|---|
| Reference | 2019-0437 |
| Deceased | Katherine Stamp |
| Coroner | James Healy-Pratt |
| Coroner area | West Sussex |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths · Mental Health related deaths |
| 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 NOTE This form ts to be used after an inquest REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: Simon Stevens, The Chief Executive of the NHS 1 | CORONER lam Mr James Healy-Pratt, assistant coroner, for the coroner area of WEST SUSSEX 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 and INQUEST A four day Article 2 Inquest was completed on 8"" November 2019 into the death of Katharine Eva Stamp, without a jury 4 | CIRCUMSTANCES OF THE DEATH Miss Stamp died whilst detained under the Mental Health Act as a result of suddent cardiac arrythmia due to hypoxia Hypoxia was the result of a combination of physical health factors including aspiration pneumonia and probable sleep apnoea — linked to obesity, smoking and the effects of clozapine on her respiratory system The lack of any effective national weight-gain monitoring programme for mental health inpatients was casually linked to her obesity and probable sleep apnoea 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 side effects of clozapine, with specific reference to smoking and pneumonia, are under-appreciated Professo ave expert evidence to the Court These side effects may be rare, but they are still important The BNF does not provide sufficient clarity to prescribers about these side-effects 6 | ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and | believe 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 12" February 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 ts proposed | COPIES and PUBLICATION \ have sent a copy of my report to the Chief Coroner and to the following Interested Persons - - Mother of Katharine Stamp - Legal Representatives for the Family - Legal Representative for The Dene | 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 Fe Date 18” December 2019 GTB ec James Healy-Pratt, Assistant Coroner
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