Prevention of Future Deaths reports · 2021
Regulation 28 report to prevent future deaths, reference 2021-0080, written 7 Jan 2021. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 7 Jan 2021 |
|---|---|
| Reference | 2021-0080 |
| Deceased | John Berrow |
| Coroner | Caroline Saunders |
| Coroner area | Gwent |
| Category | Other 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.
Regulations 28 and 29 of the Coroners (Investigations) Regulations 2013 REGULATION 28: REPORT TO PREVENT FUTURE DEATHS REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: 1. Chief Executive, Specsavers uk CORONER ! am Caroline Saunders, Senior Coroner for the Area of Gwent 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 INVESTIGATION AND INQUEST On 18/10/19 an investigation was opened into the death of John BERROW The investigation concluded at the end of the inquest on: 1/12/20 The conclusion of the inquest was recorded as: Natural Causes The medica! cause of death was: 1a) Subarachnoid haemorrhage 1b Ruptured berry cerebral aneurysm CIRCUMSTANCES OF THE DEATH On 11" October 2019 John Berrow attended the Specsavers Opticians in Newport because he was suffering from unequally sized pupils. John stated that his eyesight was altered and he complained of increased pressure or heaviness. An examination was performed by PY the optometrist who noted the disparity in size. Mr Campbell considered whether John’s symptoms could be as a result of an aneurysm or increased intracranial pressure, but the tests he performed reassured him that John’s neurological function was intact. |_| [RR diagnosed a condition known as Adie’s pupil an unusual neurological disorder in which the ability of the pupil to constrict is impaired, usually in one eye. This is not an emergency and as a result John was referred on a routine basis to the eye hospital. John left the opticians at about 13:00hrs John then went to the Queen’s Hotel in Newport and collapsed at about 15.25pm, he was resuscitated and taken to hospital. On arrival at hospital all attempts were made to fully resuscitate John but sadly his condition was irretrievable and John died at 16:50 hours. The cause of John’s death was confirmed as a ruptured Berry Aneurysm. The neurological symptoms including unequal pupil size that John exhibited at his assessment at Specsavers should have resulted in John being advised to attend hospital for assessment. Given the severity and nature of his collapse however, there is no evidence that John’s death would have been avoided. CORONER’S CONCERNS During the course of the inquest, 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: - | oral evidence at the inquest hearing. In evidence he admitted that he failed to consider unequal pupils alone as a sign of increased intracranial pressure due to a bleed or aneurysm and has rectified this in his current practice. He also stated that there were no practical reference tools or clinical manuals available to him within Specsavers and was dependent upon referring to Google to assist him in his clinical decision making. | was also informed that whils shared his experience locally, that there is no mechanism for disseminating information relating to clinical incidents or to improve learning from similar events amongst practitioners at Specsavers. ACTION SHOULD BE TAKEN ae | In my opinion action should be taken to prevent future deaths and | believe you have “| the power to take such action. | should be grateful if the following information be provided to me: Confirm the resources available for clinical staff working at Specsavers to access up to date clinical information relating to potentially life threatening conditions. Confirm how information relating to Mr Berrow’s death and his presentation is to be disseminated to minimize the risks of missing symptoms allied to Berry Aneurysms in the future. 7 YOUR RESPONSE | You are under a duty to respond to this report within 56 days of the date of this report, namely 4/3/2023 |, the Coroner, may extend this 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 necessary COPIES AND PUBLICATION | have sent a copy of my report to the Chief Coroner and the following Interested Person (s) . The family of John Berrow lam 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 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. DATE 7/1/2021 Signed Chorcler Caroline Saunders Her Majesty’s Senior Coroner for the Area of Gwent.
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.
Specsavers 4 March 2021 Dear Ms Saunders Regulation 28 report — John Berrow (deceased) Your letter of 7 January 2021 enclosing your Regulation 28 report has been forward to me as the Professional Services Consultant for Specsavers. I write on behalf of the Specsavers Optical Group to respond to the matters raised in your report. Firstly, I would like to offer my condolences to Mr Berrow’s family for their loss. So far as reference tools and clinical manuals are concerned, we do not provide paper textbooks and manuals within the stores as these will become out-of-date — however, computers are provided and staff are able to access clinical evidence, guidance, journals and optometry textbooks via the College of Optometrists website. This has the benefit of being up-to-date. Staff also have access to peers and more senior colleagues within the store or through the professional services team, which can give advice. My understanding is that the optometrist accessed the publically available local referral guidelines online to ensure that he followed the current, up-to-date referral guidelines. Each area will have its own guidelines. This was an unusual presentation. We appreciate the importance of sharing experience and learning across the Company. We are liaising with Specsavers Professional Training team to commission a specialist optometrist or neuro-ophthalmologist to deliver training materials (concentrating on this topic) which will be recorded and disseminated via an online webinar or other similar mechanism which will be available to all Professional staff within the Company. We also hope to make the training available for the wider optical community outside the Company so that there is an opportunity for non-Specsavers practitioners to learn any and all matters arising out of Mr Berrow’s sad death. If I can provide any further information, please do not hesitate to contact me. Yours sincerely Di Professional Services Consultant
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