Prevention of Future Deaths reports · 2021
Regulation 28 report to prevent future deaths, reference 2021-0042, written 12 Feb 2021. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 12 Feb 2021 |
|---|---|
| Reference | 2021-0042 |
| Deceased | Lucy Colgate |
| Coroner | Caroline Topping |
| Coroner area | Surrey |
| Category | Other related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 2 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
IN THE SURREY CORONER’S COURT IN THE MATTER OF: LUCY PATRICIA COLGATE __________________________________________________________ The Inquest Touching the Death of LUCY PATRICIA COLGATE A Regulation 28 Report – Action to Prevent Future Deaths __________________________________________________________ THIS REPORT IS BEING SENT TO , President of the Association of British Neurologists. , Chief Executive of Epilepsy Action. President of the Royal College of Paediatrics and Child Health 1 CORONER I am Caroline Topping HM Assistant Coroner, for the coroner area of Surrey 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 An inquest into the death of Lucy Patricia Colgate was opened on the 12th May 2020 and resumed on the 12th January 2021. The inquest concluded on 29th January 2021. I found that the medical cause of her death was; 1a. Positional Asphyxia 1b. Uncontrolled Epilepsy I concluded with a Narrative Conclusion: Lucy Patricia Colgate suffered from generalised epilepsy which was poorly controlled on medication which had been appropriately prescribed. On the 28th March 2019 she had an epileptic fit at home and became wedged behind a door so that the door could not be opened. She was in a prone position. Paramedics attended promptly and managed to gain access to her within 20 minutes by which time she had suffered a hypoxic cardiac arrest through positional asphyxia and the effect of being in a post ictal state. She was taken by ambulance to Royal Surrey County Hospital but pronounced dead on arrival. 4 CIRCUMSTANCES OF THE DEATH The circumstances of the death are detailed in the narrative conclusion. 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. – The evidence showed that: 1. who was Lucy Colgate’s Consultant Neurologist gave evidence that the risks posed to epilepsy sufferers from locked doors is a recognised risk but that the risk posed by having inward opening doors to confined spaces is not widely appreciated. If the door had been outward opening Lucy Colgate is likely to have survived. 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe your organisation has 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 7.4 2021. 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; and Royal Surrey County Hospital I am also under a duty to send a copy of your response to the Chief Coroner and all interested persons who in my opinion should receive it. I may also send a copy of your report to any other person who I believe may find it useful or of interest. 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 Signed: Caroline Topping Dated this 12th February 2021.
2 responses 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.
Dear Response to Regulation 28 Report – Action to Prevent Future Deaths – 12 February 2021 My apologies for the somewhat late reply to your request. I can advise the following. Epilepsy Action’s current position Our five advice and information officers were asked if blocked doors was a significant or frequent enquiry. Two said they had never encountered this. Three who have had calls on this subject report it to be a rare and infrequent occurrence. When it has happened it has related to bathrooms or toilets (small rooms) with inward opening doors where a person has had (or could have) a seizure, loses consciousness and becomes wedged against the door in the tight space preventing the door from being opened. The concern raised is not so much that it has happened but that the risk has been identified by the person concerned and they want to avoid it. The low level of enquiries means our advice and information service doesn’t have a category specific to this issue. Enquiries of this nature would be classified under the general category of ‘safety’. In 2019, our Helpline advice and information service was used 11,771 times. 102 enquiries (0.87%) were about ‘safety’ in all its forms. In addition, there were 147 enquiries (1.25%) about daily living aids or adaptations which might also be relevant here. What our current advice and information says Within our website advice and information section is a page https://www.epilepsy.org.uk/info/daily- life/safety/practical-guidance Here we advise the following: • Have a bathroom door that opens outwards, or folds or slides open and closed. Then, if you fall against it during a seizure, you won’t block someone from getting in Our written advice references bathroom doors only. This reflects the enquiries we receive. The same advice could be extended to any door to any confined space. We will make this amendment to our online information by the end of June 2021. Relevant printed information is due for reprint in July 2021. We will update this in the same way at that time. The verbal advice given by our officers responds to the specific nature of the enquiry being dealt with. Currently, if appropriate, we already extend our advice to cover all doors to any confined space. This will continue. What else we will do During the course of 2021 we will publish an article in our magazine Epilepsy Today to raise awareness about this issue. This will include referencing and signposting people to sources of funding that might be available such as grants for home adaptations. During the course of 2021 we will notify our healthcare professional contacts about what we’re doing and why so as to increase their awareness about the issue and to guide them in providing appropriate advice to their patients. We will continue to monitor the number and type of enquiries we receive on this topic and adapt our responding materials accordingly. Yours sincerely Keep in touch with Epilepsy Action for updates and news or change your contact preferences View our email disclaimer View our updated privacy statement, updated March 2019 Epilepsy Action is a working name of British Epilepsy Association. British Epilepsy Association is a registered charity (registered in England No. 234343) and a company limited by guarantee (registered in England No. 797997)
Thursday, 01 April 2021 Sent by email to: Dear Coroner C Topping Re: Lucy Patricia Colgate Regulation 28 – Action to Prevent Future Deaths We have read carefully your report regarding the tragic and untimely death of Lucy Colgate and have discussed this with senior colleagues within the RCPCH Epilepsy Programme Board and with the British Paediatric Neurology Association’s British Paediatric Epilepsy Group in order to respond to your request. The RCPCH supports, educates and develops paediatricians, and the wider child health workforce and services, to deliver high quality safe care for infants, children and young people. Given that we do not have all the details of the tragic death of Lucy Colgate, the RCPCH is unable to comment on the specifics of the case. Children and young people with epilepsy need support to engage in an ongoing individualised assessment of risk and consideration of tailored accident prevention. The RCPCH Epilepsy12 audit supports trusts in England and Wales to measure on an ongoing basis how well they are evidencing risk assessment. The September 2020 report found that the majority (80%) of children and young people diagnosed with epilepsy had evidence of discussion regarding general participation and risk.1 The RCPCH continue to monitor and share audit results with local and regional teams and further urge quality improvement in this area. The Sudden Unexpected Death in Epilepsy charity (SUDEP Action)) has produced resources for parents and carers to support individualised understanding and balancing risk for children living with an epilepsy.2 There may be opportunity to adjust specific advice regarding door opening in their information resources. At the moment the information leaflet makes this recommendation only for bathroom doors. We will share learning around the circumstances of this death with our paediatric specialty groups who lead care for children with epilepsy and with OPEN UK3 (Organisation of Paediatric Epilepsy Networks) to disseminate warnings of these types of risks. We hope 1 https://www.rcpch.ac.uk/sites/default/files/2020-09/epilepsy12_2020_national_report_final_2.pdf 2 https://sudep.org/sites/default/files/sudep_childrens_hi.pdf 3 https://www.rcpch.ac.uk/resources/open-uk-organisation-paediatric-epilepsy-networks-uk that in doing so, families will be more aware of the key factors that are critical to ensuring suitable home environments for children and young people with epilepsy. We are pleased that you have shared your report with Epilepsy Action who have a collection of useful resources to support safety at home. Thank you for raising this case with us and reminding us of the importance of this work. Yours sincerely President, Royal College of Paediatrics and Child Health
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