Prevention of Future Deaths reports · 2023
Regulation 28 report to prevent future deaths, reference 2023-0153, written 12 May 2023. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 12 May 2023 |
|---|---|
| Reference | 2023-0153 |
| Deceased | Barbara Mitchell |
| Coroner | Peter Straker |
| Coroner area | London (North) |
| Category | Care Home Health 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.
Her Majesty’s Coroner for the
Northern District of Greater London
(Harrow, Brent, Barnet, Haringey and Enfield)
North London Coroners Court,
29 Wood Street,
Barnet EN5 4BE
E-mail:- admin.beh@hmc-northlondon.co.uk
REGULATION 28 REPORT TO PREVENT FUTURE DEATHS
THIS REPORT IS BEING SENT TO:
Bluebird Care (Brent)
107 Kenton Road
Harrow
Middlesex HA3 0AN
1
CORONER
I am Peter Straker, Assistant coroner, for the coroner area of Northern District of
Greater 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.
3
INVESTIGATION and INQUEST
On the 13th July 2022 I opened an investigation touching the death of Barbara Mitchell ,
aged 94 years old. I opened and heard an inquest on the 7th December 2022. The
conclusion of the inquest was “ Barbara Mitchell died as the result of an accident ”, the
medical case of death was 1a Pneumonia, 1b Fracture of Sternum and under paragraph
2 Atrial Fibrillation.
CIRCUMSTANCES OF THE DEATH
On the 9th July 2022 Barbara Mitchell died at Northwick Park Hospital
having fallen at home despite being assisted at the time by a carer.
4
5
CORONER’S CONCERNS
The MATTERS OF CONCERN are as follows. –
1. Consideration of specialist training of staff in connection with the moving and
handling of individuals, especially after a fall.
6
ACTION SHOULD BE TAKEN
In my opinion action should be taken to prevent future deaths and I believe you
[AND/OR your organisation] have the power to take such action.
7
YOUR RESPONSE
Her Majesty’s Coroner for the
Northern District of Greater London
(Harrow, Brent, Barnet, Haringey and Enfield)
You are under a duty to respond to this report within 56 days of the date of this report,
namely by Friday the Seventh of July 2023 I, the assistant 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;-
-
The Family
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
12-5-2023
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