Prevention of Future Deaths reports · 2023
Regulation 28 report to prevent future deaths, reference 2023-0455, written 15 Nov 2023. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 15 Nov 2023 |
|---|---|
| Reference | 2023-0455 |
| Deceased | Ocean-Leigh Hayes |
| Coroner | Rachel Knight |
| Coroner area | South Wales Central |
| Category | Child Death (from 2015) |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
GRAEME HUGHES
HIS MAJESTY’S
SENIOR CORONER
SOUTH WALES CENTRAL
CORONER AREA
CORONER’S OFFICE
THE OLD COURTHOUSE
COURTHOUSE STREET
PONTYPRIDD
CF37 1JW
Telephone: 01443 281100
Email: Coroneradmin@rctcbc.gov.uk
ANNEX A
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:
The Chief Executive Cardiff & Vale University Health Board
1
2
3
CORONER
I am Rachel Knight Assistant Coroner for the coroner area of South Wales Central.
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 29 December 2021 I commenced an investigation into the death of Ocean-Leigh Pauline
Jean Hayes. The investigation concluded at the end of the inquest on 15th November 2023.
The conclusion of the inquest was Sudden Unexplained Death in Infancy, as there was
insufficient evidence of any other natural or unnatural factor.
1a Sudden Unexplained Death in Infancy
1b
1c
II
4 CIRCUMSTANCES OF THE DEATH
Coroner’s Office, The Old Courthouse, Courthouse Street, Pontypridd, CF37 1JW
These were recorded as :-
Ocean-Leigh Pauline Jean Hayes was aged 4 months when on 22nd December 2021, she
died at her home address of 58 Snowden Road, Ely, Cardiff. Ocean had been co-sleeping
with her mother in the hours and minutes before she died.
The Inquest focused upon:-
a. The arrangements for sleeping with a newborn infant and the pathology evidence.
.
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.
5
(1) Guidance requires health visitors to physically review sleeping arrangements before
the baby is 6 weeks old.
(2) I heard evidence that this was not always being done.
(3) There may be missed opportunities to physically risk assess sleeping arrangements
including inter alia bedding, blankets, pillows, mattress and positioning, particularly where
co-sleeping is a factor, and missed opportunities to advise parents on risks they may be
taking.
6
7
8
ACTION SHOULD BE TAKEN
In my opinion action should be taken to prevent future deaths and I believe you and your
organisation have the power to take such action.
YOUR RESPONSE
You are under a duty to respond to this report within 56 days of the date of this report,
namely by 10th January 2024. or if 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.
COPIES and PUBLICATION
I have sent a copy of my report to family members, and the Nursing and Midwifery Council
who may find it useful or of interest.
Coroner’s Office, The Old Courthouse, Courthouse Street, Pontypridd, CF37 1JW
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.
15 November 2023
SIGNED:
9
Assistant Coroner
for South Wales Central Coroner Area
Coroner’s Office, The Old Courthouse, Courthouse Street, Pontypridd, CF37 1JW
Phone/Ffôn (01443) 281100 Fax/Ffacs (01443) 485862
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.
Bwrdd lechyd Prifysgol Caerdydd a' r Fro Executive Headquarters/ Pencadlys Gweithredol Cardiff and Vale University Health Board Maes-y-Coed Road Woodland House Eich cyr/Your ref: 3610 Eln cyf/Our ref: SR·jtf-1223-10432 Welsh Health Telephone Network: Direct Llne/Llinell unrongychol ; 02921 836319 Cardiff CF14 4HH Ty Coedtir Ffordd Maes-y-Coed Caerdydd CF14 4HH 28th December 2023 Private and Confidential Mr Graeme Hughes Senior Coroner Coroner's Office The Old Courthouse Courthouse Street Pontypridd CF371JW Dear Mr Hughes Thank you for your letter received via email on the 20 November 2023, in which you have shared the Regulation 28 with associated actions for improvement following the inquest into the sad death of Ocean-Leigh Pauline Jean Hayes who sadly died in early infancy aged just 4 months in 2021. I note that whilst the conclusion was Sudden Unexplained Death in Infancy it is your view that some actions could be taken by the Health Board to minimise the risk of future deaths in similar circumstances. From your findings it became evident that the sleeping arrangements were not being physically reviewed by Health Visitors in all cases before a baby is 6 weeks old. The evidence you heard additionally raised concerns as to whether parents were being reminded of the risks of co-sleeping at all opportunities and the risks of bedding and pillows and so on. In order to review the pathways of education of the Health Visitors and communication with parents we have held several multidisciplinary meetings to consider the communication provided and to discuss where improvements could be made. Please find attached our assurance and improvement plan which has identified all opportunities for improvement and details the actions that have been and are being progressed to minimise the risk of any missed opportunities in the future. In summary, Cardiff and Vale UHB will monitor and implement the assurance plan to completion through the Children and Women Clinical Board assurance framework. 1 I hope that this information is helpful and offers the assurance you are seeking regarding the improvements instigated to ensure patients and their families in similar circumstances will be provided with the relevant information to consider the risks of co-sleeping and that Health Visitors will undertake the visual assessment of the baby's sleeping area before 6 weeks. Yours sincerely Chief Executive Enc Assurance and Improvement Plan 2
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