Prevention of Future Deaths reports · 2019
Regulation 28 report to prevent future deaths, reference 2019-0495, written 26 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 | 26 Nov 2019 |
|---|---|
| Reference | 2019-0495 |
| Deceased | Trevor Oakley |
| Coroner | Samantha Marsh |
| Coroner area | Hampshire |
| Category | State Custody related deaths |
| 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.
ANNEX A REGULATION 28: REPORT TO PREVENT FUTURE DEATHS (1) REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: 4. HM Prison Service of 102 Petty France, London SW1 9EX, (FAO The CEO Ms Jo Farrar) CORONER lam Samantha Marsh, Area Coroner, for the coroner area of Hampshire [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. | INVESTIGATION and INQUEST On 30" October 2018 | commenced an investigation into the death of Trevor Albert Oakley, who was 74 years old. The investigation concluded at the end of the inquest on 234 October 2019. The conclusion of the inquest was that Mr Oakley's death was due to suicide, with a medical cause of death as: 1a. Ligature suspension. | CIRCUMSTANCES OF THE DEATH At 06:26 hours on the Twenty-second of October 2018 Trevor Albert Oakley was found hanging from the window bars in his cell. He had suspended himself from a ligature made of a bedsheet. He was hidden behind a non-prison issue ‘privacy curtain’. He was pronounced deceased at 06:50am by attending paramedics. Mr Oakley was due to start his Trail at Salisbury Crown Court that morning (the 22™4 October 2018) for serious sexual offences. Mr Oakley was remanded to HMP Winchester on the 14!" February 2018. Prior to his remand he had taken an intentional overdose of insulin and prescription mediation on the 28" January 2018; being the day that officers from Hampshire Police had attended to arrest him on suspicion of committing the sexual offences for which he was ultimately due to stand trial. He was hospitalised for 8 days and on discharge from hospital was admitted to a psychiatric ward. On discharge from the psychiatric ward he was arrested and on appearing before Basingstoke Magistrates Court on the 14‘ February 2018 he was remanded into custody. Mr Oakley had three ACCTS opened whilst he was in prison; the last of which was opened on the 8 August 2018 and closed the following day, namely the gir August2019. This related to issues of alleged bullying of Mr Oakley by his cellmate. Between August and the date of his death there was no involvement of mental health. On the 22" October 2018 Mr Oakley was due to start his trial. 1 head evidence that he would have been aware of this date, most likely via his legal representative, and the trial would have been the first time he would have faced his family since they had made serious allegations against him for sexual assault (of his daughters and grandchildren). | heard evidence from witnesses within the Health Service at the Prison that Mr Oakley had a pattern of being unwell on the occasions when he was due to attend Court, and so the start of his trial is likely to have been a stressful time for him. 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) | was told that the Courts will supply the Prison with a list of prisoners who are required for trial the following day, (“the List”). The List is circulated within the prison by the OMU (Offender Management Unit) and the overnight staff should receive the List to enable them to know which particular prisoners need to be unlocked for Court attendances the following day. | was told that the Night Orderly Officer will brief the night shift officers on the wings as to what is due to be happening over the course of the night shift, but it was the evidence of more than one Prison Officer on duty that there was no notification of the prisoners due in Court the next morning. The stance adopted within the prison appeared to be that the information was available if a Prison Officer wanted to go and look for it within the system. | am concerned that within the Prison it is not immediately apparent to the night Staff who is due in Court the following morning an from this, it flows, that any increased risk of self-harm by such prisoner(s) is not identified. (2 6 | ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and | believe you and/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 the 21st January 2020. |, 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 who may find it useful or of interest. (i) HM Inspectorate of Prisons at HM Inspectorate of Prisons, 3rd floor 10 South Colonnade, Canary Wharf, London E14 4PU; and (ii) Independent Advisory Panel on Deaths in Custody of 9" Floor, 102 Petty France, London SW1H 9AJ (ii) SR Governor of HMP Winchester (iv) The next of kin | 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 | 26th November 2019 SND.
EG Mark Bricknell Senior Coroner tor County of Herefordshire REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: Mr Glen Burley, Chief Executive, Wye Valley NHS Trust CORONER iam Hugh Gregory Mark Sricknell, Senior Coroner for County of Herefordshire GORONER’S LEGAL POWERS ' make this report under paragraph 7, Schedule §, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (investigations) Regulations 2013. htto:/Amww legislation.gov.uk/ukpga/2009/25/schedule/5/paragraph/7 htto:/Awww.legistation.gov.uk/uksi/2013/1629/part/7/made INVESTIGATION and INQUEST On the 1st day of August 2018 | commenced an investigation into the death of Mary Bertha Johnson CIRCUMSTANCES OF THE DEATH Mrs Mary Bertha Johnson died on the 25th July 2018 at the County Hospital, Hereford. Mrs Johnson had fallen on the 20th July 2018 causing a periprosthetic fracture of the fernur. 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. ~ [BRIEF SUMMARY OF MATTERS OF CONCERN] (1) A lack of communication between staff highlighted issues concerning: (a) the feeding of patients prior to operation (b) adherence to the Consultant's instructions regarding the provision of medication prior to operation (2) It was suggested that the availability of porters determined the ability of the hospital theatres to carry out operations Town Hall, St Owen Street, Hereford, HR1 2P7 Tel 01432 261813 | Fax 01432 261720 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and | believe you have the power to take such action. 4 YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by the 29th March 2079 |, 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 seni_a copy of my report to the Chief Coroner anc to the following interested Persons: | Operational Medical Director, Wye Valley NHS Trust. | 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. Dated _ : f in Rb wd AT |) ~ . ~ Signature W AAAAA AAA HG. GROG wee CORR RE for County of Héréferdshire Town Hall, St Owen Street, Hereford, HRI 2PI Tel 01432 261813 | Fax 01432 261720
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.
Wye Valley NHS Trust Private & Confidential Corporate Executive County Hospital H G Mark Bricknell Union Walk H.M. Senior Coroner :Herefordshire Hereford Town Hall HR1 2ER St Owens Street Tel: 01432 364000 Ext. atte Hereford A HR1 2JP Date: 19" March 2019 Re: Regulation 28 report to prevent future deaths, with regards to Mary Bertha Johnson Dear Mr Bricknell We have now had the chance to investigate the circumstances around the death of Mrs Johnson. With reference to section 5 of your regulation 28 report, entitled coroners concerns, | would like to answer the points you raise in turn. 1. A lack of communication between staff:- a) Feeding the patients prior to operation b) Adherence to the consultants’ instructions Following our investigations, | can confirm that the patient was fed appropriately throughout her stay on the ward and placed nil by mouth, i.e. food and fluids restricted appropriately, prior to the planned operation on Tues 24¢ July 2018. The investigation has established that the consultants’ instructions were not adequately adhered to over the weekend in question. The plan, quite clearly placed in the notes by the consultant team, was for Mrs Johnson to be operated on Monday 23" July. Fortunately, this instruction appears not to have been read by the nurse caring for the patient over the weekend in question. This nurse appeared to have been under the impression that this patient was to be operated on over the weekend and hence withheld the prescribed thrombo prophelaxysis. 2. Availability of porters:- The investigation has established that the availability of porters had no material effect on this patient's outcome. The nurse has been. asked to reflect on the need to read the medical notes of the patients for which he cares closely and adhere to them to the letter. He has also been advised to discuss any uncertainty with the medical team in question. Glen Burley, Chief Executive , Russell Hardy, Chairman . . fe i Amnarcinn a geri intalilion,s ) ee oe et Pe Although not actually the root cause for this patient’s death, we have also taken the opportunity to relaunch and clarify to all pertinent staff, the use of thromboprophylaxis prior to surgery, particularly the time period before which it should be withheld. In addition to this, and this is an ongoing piece of work, all speciality specific thromboprophylaxis guidelines are being reviewed and | would be happy to update you on the progress of this a later date. | trust this answers all the outstanding questions you have for this sad case but | would be more than happy to meet with you in person to clarify any other details. Best wishes Yours Sincerely ( David Mowbray Medical Director Cc Glen Burley — Chief Executive Wye Valley Trust. Glen Burley, Chief Executive Russell Hardy, Chairman
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