Prevention of Future Deaths reports · 2023
Regulation 28 report to prevent future deaths, reference 2023-0310, written 24 Aug 2023. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 24 Aug 2023 |
|---|---|
| Reference | 2023-0310 |
| Deceased | Christopher Locke |
| Coroner | Aled Gruffydd |
| Coroner area | Swansea Neath Port Talbot |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
REGULATION 28: REPORT TO PREVENT FUTURE DEATHS (1)
NOTE: This form is to be used after an inquest.
REGULATION 28 REPORT TO PREVENT FUTURE DEATHS
THIS REPORT IS BEING SENT TO:
JD WETHERSPOONS PLC
WETHERSPOON HOUSE
CENTRAL PARK
REEDS CRES
WATFORD
WD24 4QL
1
CORONER
I am Aled Gruffydd, Assistant Coroner, for the coroner area of SWANSEA NEATH &
PORT TALBOT
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 11th August 2022 I commenced an investigation into the death of Christopher
James Locke. The investigation concluded at the end of the inquest on the 24th of
August 2023.
The medical cause of death is
1a) hypoxic ischaemic encephalopathy
1b) cardiac arrest
1c) cardiac arrhythmia in a man with a fatty heart who had sustained a blow to the head
The conclusion of the inquest as to how Mr Locke came to his death was a narrative
conclusion and is as follows:-
The deceased died from hypoxic ischaemic encephalopathy, caused by a cardiac arrest,
which itself was caused by a cardiac arrhythmia in a man with a fatty heart and
sustained a blow to the head. The emergency services did not instruct the caller to
initiate chest compressions when given sufficient information to give that instruction, and
this more than minimally contributed to the deceased’s death
4
CIRCUMSTANCES OF THE DEATH
The deceased was Christopher James Locke and he was pronounced dead on the 29th
October 2021 at Morriston Hospital, Swansea. The cause of death was hypoxic
ischaemic encephalopathy, caused by a cardiac arrest, which itself was caused by a
cardiac.
Christopher was admitted to Morriston Hospital via UHW Hospital Cardiff on the 23rd
1
October 2021 having sustained a cardiac arrest at the Lord Cradoc public house, Port
Talbot during the evening of the 21st of October 2021. The cause of the cardiac arrest
was found to be a cardiac arrhythmia. The staff at the Lord Cradoc called 999 and
followed the instructions provided by the Emergency Medical Dispatcher (EMD). The
EMD did not instruct the staff to undertake CPR. Christopher’s circulation was restored
12 minutes after the arrival of the paramedics, who arrived 8 minutes after the
commencement of the call. It was therefore estimated that Christopher had been without
oxygen for at least 20 minutes. Christopher died from a brain injury caused by this lack
of oxygen.
5
CORONER’S CONCERNS
During the course of the inquest it transpired that there had previously been a scheme
undertaken by Wetherspoons allowing staff to undertake additional training including
CPR training. The evidence that was heard from a Consultant Intensivist was that the
sooner that CPR can be commenced the greater chance that a person is able to survive
a cardiac arrest, with minimal if no long lasting disabilities. The inquest concluded that
the EMD should have directed staff at the Lord Cradoc to commence CPR and it is
understood that compulsory training has been given to all Wetherspoons staff to enable
them to comply with EMD instructions. This compulsory training dod not extend to CPR
training.
It is not the purpose of this report to compel your organisation to provide CPR training to
its staff but to make such training available to staff who express an interest. It is
recognised that such situations are stressful situations and that it would be unfair to
impose compulsory CPR training to staff, however as with all organisations some
individuals would welcome the opportunity to benefit from such training. No failings were
found against the staff who attended to Christopher that evening and they ought to be
commended for their actions.
I am concerned that in such cases bar staff at pubs will invariably find themselves in
situations where the administering of emergency CPR treatment ought to be
administered. The time taken between the beginning of an emergency call and an
instruction to commence CPR may deprive a patient of a favourable outcome. Whilst
Wetherspoons staff have been trained to comply with EMD instructions there are
occasions such as this case where staff could implement CPR of their own accord
before being instructed to do so by EMD’s. The training would not only teach staff the
correct techniques but educate them of the situations in which CPR should be used.
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.
In a pub environment there is a greater chance for the public to sustain injuries
that requires emergency treatment
2. Ordinary bystanders’ ability to administer emergency treatment may be hindered
by their own consumption of alcohol
3. Whilst the primary responsibility of staff is to comply with EMD directions they
are deprived of the opportunity to provide lifesaving treatment in circumstances
that warrant it if that training is not offered
4. Staff would not know the circumstances that warrant it without the benefit of
CPR training.
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.
2
7
YOUR RESPONSE
You are under a duty to respond to this report within 56 days of the date of this report,
namely by 19 October 2023. 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
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
24 August 2023
[SIGNED BY CORONER]
3
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.
Response to Regulation 28 Report – Christopher Locke Deceased J D Wetherspoon PLC (“Wetherspoon”) was very sorry to have learnt about the passing of Mr Locke. On hearing evidence at the Inquest we understand why the Coroner has raised the Regulation 28 Report. We are aware that the Coroner has also contacted a trade body to also look into the provision of CPR training across the wider licensed industry. We note that incorrect evidence was given by Wetherspoon employees at the Inquest to the effect that “there had previously been a scheme offered to undertake additional training including CPR training”. That position is not correct. Wetherspoon have a policy that if any customers or staff get into a medical emergency, care is provided by appropriately trained medical professionals. It is therefore Wetherspoon’s policy that for any injury or medical incident that requires immediate attention, emergency services are called and an ambulance is requested. Wetherspoon does not provide or offer medical training (which would include CPR training) to its staff as it feels a qualified medical professional is best place to provide it. This policy has been in place for 25 years and has been reviewed by and assured advice has been received from Wetherspoon’s Primary Authority. Wetherspoon has reviewed the position in relation to offering CPR training since receiving the Regulation 28 Report but will not be making any changes to the existing policy.
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