Prevention of Future Deaths reports · 2022
Regulation 28 report to prevent future deaths, reference 2022-0062, written 28 Feb 2022. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 28 Feb 2022 |
|---|---|
| Reference | 2022-0062 |
| Deceased | Vijaykumar Gadhavi |
| Coroner | Nadia Persaud |
| Coroner area | East London |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths · Alcohol, drug and medication 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.
MISS N PERSAUD
HER MAJESTY’S CORONER
EAST LONDON
EAST LONDON CORONERS, ADULT LEARNING COLLEGE, 127 RIPPLE ROAD, BARKING, IG11 7PB
Telephone 020 8496 5000 Email coroners@walthamforest.gov.uk
REGULATION 28: REPORT TO PREVENT FUTURE DEATHS (1)
REGULATION 28 REPORT TO PREVENT FUTURE DEATHS
THIS REPORT IS BEING SENT TO:
, Chief Executive, Barts Health, Royal London
Hospital, Whitechapel Road, Whitechapel, London, E1 1BB
1
CORONER
I am Nadia Persaud area coroner for the coroner area of East London
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.
http://www.legislation.gov.uk/ukpga/2009/25/schedule/5/paragraph/7
http://www.legislation.gov.uk/uksi/2013/1629/part/7/made
3
INVESTIGATION and INQUEST
On the 11th December 2020 I commenced an investigation into the death of Vijaykumar
Girishbhai Gadhavi, age 33. The investigation concluded at the end of the inquest on
16th December 2021 with a narrative conclusion.
The narrative conclusion was that:
Vijaykumar Gadhavi died as a result of a drug overdose whilst he was an in-patient in
hospital. He had a known risk of overdosing on hospital wards and had been placed
under enhanced care (one to one supervision). There were numerous breaches of the
enhanced care policy during the shift when Vijay was able to take the fatal, excessive
amount of medication. The evidence does not reveal precisely how and when Vijay took
1
the drug overdose. There is no evidence that he intended to bring about his death at
that time.
4
CIRCUMSTANCES OF THE DEATH
Mr Gadhavi suffered from chronic pancreatitis, mild learning disability and possibly a
persistent somatoform pain disorder (the latter was under investigation at the time of his
death). In July and August 2020, whilst an in-patient at Whipps Cross Hospital and
whilst under enhanced (1:1 care), Mr Gadhavi carried out a number of self-harming acts.
These included overdoses and an attempt to jump from a hospital bridge.
On one occasion in August 2020, the member of staff allocated to provide 1:1 care to
him, was found to be sleeping. In September 2020, Mr Gadhavi required admission to
Whipps Cross Hospital again. There was no alert on his medical records to alert staff to
the need for a risk assessment and risk management plan. Fortuitously, he was
recognised by a member of staff who had cared for him previously and enhanced care
was put in place. Unfortunately, there were a number of breaches of the enhanced care
policy. Mr Gadhavi was able to take a fatal overdose of medication whilst he was in in-
patient on the ward.
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. Datix reports were generated for the multiple self-harming incidents in July and
August 2020. There was no evidence at the inquest, that action and learning
had been put in place as a result of these incidents.
2. Despite the multiple risk incidents and foreseeability of future hospital
admissions, there was no alert or flag placed on Mr Gadhavi’s records to alert
new staff to the complexities and risk in his presentation.
3. Despite awareness of the previous overdoses on the ward, there was no
itemised property list, including a list of medications.
4. The recommendations by the learning disability nurse were not fully put into
practice. In particular, there was insufficient involvement of his family.
5. There were multiple breaches of the Enhanced Care Policy. There was no risk
assessment by the allocated nurse; no consideration of the need to break up the
shift of the 1:1 carer and no hourly observations kept by the 1:1 carer.
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 26 April 2022. 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 am sending a copy of my report to the Chief Coroner, to the family of Mr Gadhavi, the
CQC, the local Director for Public Health and to North East London Foundation Trust.
2
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 response 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.
9
28 February 2022
[SIGNED BY CORONER]
3
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