Prevention of Future Deaths reports · 2019
Regulation 28 report to prevent future deaths, reference 2020-0120, written 27 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 | 27 Dec 2019 |
|---|---|
| Reference | 2020-0120 |
| Deceased | Enid Baber |
| Coroner | Gordon Clow |
| Coroner area | Nottingham and Nottinghamshire |
| Category | Other 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.
REGULATION 28: REPORT TO PREVENT FUTURE DEATHS (1) REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: 1. The Corporate Direct of Adult Services, Nottinghamshire County Council, County Hall, West Bridgford, Nottingham NG2 7QP 1 CORONER Mr Gordon Clow, Assistant Coroner, for the coroner area of Nottinghamshire 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 27th June 2019 an inquest was opened touching upon the death of Enid Baber Dec’d, who was aged 85 years at the time of her death on 28th April 2019. The investigation concluded at an inquest which I heard on 27th and 28th November 2019. The conclusion was the short form conclusion of “Accidental death”. 4 CIRCUMSTANCES OF THE DEATH Mrs Baber was cognitively impaired at the time she died which led to her making a decision to run a bath late at night or in the early hours of the morning. This was entirely out of character for her and was an irrational decision, given that she had had a thorough wash on the 27th April 2019. Mrs Baber either got into the bath backwards or fell backwards into the bath, following which she died suddenly. 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. – Enid Baber was not free to leave her property. This was a fact which was well known to Nottinghamshire County Council who had been involved in coordinating her package of care. She was also under a measure of supervision and control during the day. I concluded, after hearing evidence on the point, that although in my finding she was not being deprived of her liberty, this was a very finely balanced decision. I was advised that Nottinghamshire County Council has a team which deals with deprivation of liberty (‘DOL’) in community settings although the evidence I received was that the team dealing with dementia cases did not routinely or actively carry out an assessment as to whether or not persons in Mrs Baber’s situation are deprived of their liberty. They have not received specific training on this difficult assessment process. In this case, Mrs Baber’s circumstances fell only narrowly short of a deprivation of liberty and only minor changes would have resulted in a different conclusion. There was no mechanism by which the social workers working with Mrs Baber were required or prompted to consider the issue of deprivation of liberty and they had not been trained to 1 do so. Had Mrs Baber been deprived of her liberty then she has a human right for that detention to be kept under review and I remained concerned that this particular class of persons, that is, persons who remain in their own home but who have significant restrictions on their liberty, may be unlawfully deprived of their liberty without adequate safeguards being in place and that this may potentially become unsafe by, for example, insufficient attention to the safety implications of being locked in your own home. 6 ACTION SHOULD BE TAKEN In my opinion, action should be taken to prevent future deaths and I believe you 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 24 July 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: - - 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 27th December 2019 Mr Gordon Clow, HMAC 2
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