Prevention of Future Deaths reports · 2024
Regulation 28 report to prevent future deaths, reference 2024-0503, written 19 Sep 2024. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 19 Sep 2024 |
|---|---|
| Reference | 2024-0503 |
| Deceased | Gordon Long |
| Coroner | Graeme Irvine |
| Coroner area | East London |
| Category | Hospital Death (Clinical Procedures and medical management) 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.
MR G IRVINE
SENIOR CORONER
EAST LONDON
Walthamstow Coroner's Court, Queens Road Walthamstow, E17 8QP
Telephone 020 8496 5000 Email coroners@walthamforest.gov.uk
REGULATION 28: REPORT TO PREVENT FUTURE DEATHS (1)
Ref:
REGULATION 28 REPORT TO PREVENT FUTURE DEATHS
THIS REPORT IS BEING SENT TO:
•
, Chief Executive Officer, Barking, Havering & Redbridge
University Trust
Sent via email:
1
CORONER
I am Graeme Irvine, senior 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 11th July 2023, this court commenced an investigation into the death of Gordon
Long aged 73 years. The investigation concluded at the end of the inquest on 18th
September 2024. The court returned a narrative conclusion,
“George Richard Long died in hospital on 8th July 2023 the day after necessary surgery
to amputate his left leg. Mr Long died due to complications of surgery along with the
effects of multiple, pre-existing, serious medical conditions.”
Mr Gordon’s medical cause of death was determined as;
1a: Infective Exacerbation Of Chronic Obstructive Pulmonary Disease And Congestive
Cardiac Failure
1b: Septic/Gangrenous Left Foot Treated With Left Above Knee Amputation,
1
Ischaemic Heart Disease And Extensive Metastatic Carcinoma To The Liver
1c.Peripheral Vascular Disease
II. Type 2 Diabetes Mellitus, Atherosclerosis, Dyslipidaemia, Cirrhosis Of The Liver,
Depression And Previous Left Sided Cerebrovascular Accident
4
CIRCUMSTANCES OF THE DEATH
Mr Long was admitted to hospital by ambulance on 1/7/23. A preliminary diagnosis of
dry gangrene of the left foot was arrived at in the ED. A care plan was arrived at that
involved amongst other things, admission onto a ward and referral to the vascular team
for assessment.
Mr Long was not assessed by a vascular specialist until 6th July 2023, by which time he
had suffered a significant clinical decline. Surgery to amputate the effected limb was
undertaken on 7th July 2023, he died on 8th July 2023.
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. Despite undertaking a patient safety incident investigation (“PSII”) the Trust was
unable to explain why Mr Long was not referred to the vascular team after he
was admitted from ED into the medical receiving unit (“MRU”) on the morning of
2nd July 2023. The Trust struggled to identify the consultant in charge of Mr
Long’s treatment when on the MRU and could not demonstrate that the
consultant was spoken to as part of the PSII investigation. The inadequate
standard of the investigation makes the court doubt the effectiveness of the
Trust to identify and reflect upon future risks to patients.
2. Although an action plan had been agreed by the Trust to remediate the failures
in care that led to the delayed referral, no clear evidence of change was
demonstrated to the court.
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
You are under a duty to respond to this report within 56 days of the date of this report,
namely by.15th November 2024 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 the family of Mr Long and the Care Quality Commission. I have also sent it to
the local Director of Public Health who may find it useful or of interest.
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.
2
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
[DATE] 19/09/2024 [SIGNED BY CORONER]
3
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