Prevention of Future Deaths reports · 2022
Regulation 28 report to prevent future deaths, reference 2022-0238, written 3 Aug 2022. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 3 Aug 2022 |
|---|---|
| Reference | 2022-0238 |
| Deceased | Alison Dallow |
| Coroner | Hugh Bricknell |
| Coroner area | Herefordshire |
| Category | Other related deaths |
| Organisation named | Wye Valley NHS Trust |
| 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.
H G Mark Bricknell Senior Coroner for County of Herefordshire REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: , Chief Executive, Wye Valley NHS Trust. 1 CORONER I am Hugh Gregory Mark Bricknell, Senior Coroner for County of Herefordshire. 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. u k/u ksi/2013/1629/pa rt/7 /made 3 INVESTIGATION and INQUEST On 13 October 20211 commenced an investigation into the death of Alison June Dallow. The investigation concluded at the end of the inquest on 20 July 2022. The conclusion of the inquest was the following Narrative: Mrs Dallow fractured her Left Tibial Plateau following a fall. A brace reduced her mobility as did the fracture. She was not prescribed prophylaxis. Mrs Dal low died from the medical causes given. Mrs Dallow was diagnosed with Covid 19 shortly before her death. 4 CIRCUMSTANCES OF THE DEATH Alison June Dal low died from a Pulmonary Thromboembolism due to Deep Vein Thrombosis . She had restricted mobility following a fracture and fitting of a knee brace. 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. - (1) It was unclear whether the clinical advice was to 'toe touch' or stay non- weight bearing. (2) The current hospital policy in connection with reducing the risk of Venous Thromboembolism was unclear especially regarding outpatients who apparently account for the majority of fractures treated . (3) Evidence of any information given to the patient was unavailable at the Inquest. 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you, power to take such action. have the 7 YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 28 September 2022. I, the coroner, may extend th e 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. 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 compl ete 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 representation s to me, the coroner, at the time of your respon se, about the release or the publication of your response by the Chief Coroner. 9 3 August 2022 Sign a tu re_-t----+------'-----+-+-=___.c,- HG Mark Brick
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