Prevention of Future Deaths reports · 2024
Regulation 28 report to prevent future deaths, reference 2024-0649, written 25 Nov 2024. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 25 Nov 2024 |
|---|---|
| Reference | 2024-0649 |
| Deceased | Dean Bray |
| Coroner | Rachel Spearing |
| Coroner area | Hampshire, Portsmouth & Southampton |
| 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.
Regulation 28: REPORT TO PREVENT FUTURE DEATHS NOTE: This form is to be used after an inquest. REGULATION 28 REPORT TO PREVENT DEATHS THIS REPORT IS BEING SENT TO: 1 Southern Health Foundation Trust 2 Chief Coroner - PFD Reports 1 CORONER I am Mrs Rachel Spearing, Assistant Coroner for the coroner area of Hampshire, Portsmouth & Southampton 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 12 January 2022 I commenced an investigation into the death of Dean John Mark Anthony BRAY aged 47. The investigation concluded at the end of the inquest on 11 November 2024. The conclusion of the inquest was that: Mr Dean Bray died of Acute Heart Failure on the 29th December 2021 whilst in the seclusion room on Hamtun Ward where there was a failure to adequately act upon and escalate Dean's high respiratory rate by nursing staff over the 28th and 29th December 2021 4 CIRCUMSTANCES OF THE DEATH Mr Dean Bray died of Acute Heart Failure on the 29th December 2021 whilst in the seclusion room on Hamtun Ward where there was a failure to adequately act upon and escalate Dean's high respiratory rate by nursing staff over the 28th and 29th December 2021 Narrative Conclusion The Jury’s conclusion is Natural Death contributed to by Neglect. There was a gross failure to escalate Dean's deteriorating physical presentations on 28th December after 21:43 up until 08:00 on 29th December 2021, based on inadequate monitoring of Dean's physical health and a lack of recognition of Dean's medical emergency which, on the balance of probabilities but for the gross failures, Dean's life probably could have been prolonged. 5 CORONER’S CONCERNS During the course of the investigation my inquiries 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: (brief summary of matters of concern) Firstly, Staff conducting 121 observations upon a patient within the seclusion room were Regulation 28 – After Inquest Document Template Updated 30/07/2021 unable to make a direct 999 emergency call from the observation room as no outside line was available from this handset to respond to a medical emergency. Secondly, I heard evidence from Paramedics of a delay, and difficulty with accessing the patient who was being cared for in seclusion. The most immediate access route to the ward used by secure transport services being unknown by South Central Ambulance Service and not shared with them to assist responding to a medical emergency at Antelope House. 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 January 16, 2025. 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 8 I have sent a copy of my report to the Chief Coroner and to the following Interested Persons Southern Health Foundation Trust I have also sent it to South Central Ambulance Service legal SCAS 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. I may also send a copy of your response to any 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 by the Chief Coroner. 9 Dated: 25/11/2024 Rachel SPEARING Assistant Coroner for Hampshire, Portsmouth and Southampton Regulation 28 – After Inquest Document Template Updated 30/07/2021
Chief Medical Officer Sterne 7 Tatchbury Mount Calmore Southampton SO40 2RZ Our Ref: 15 January 2025 Private & Confidential Rachel Spearing HM Assistant Coroner, Coroner’s Office The Castle Castle Hill Winchester SO23 8UL Dear Ms Spearing, I write further to the conclusion of the inquest of Mr Dean Bray on 11 November 2024, and in response to the Regulation 28 report that you issued. Matter of Concern 1: Infrastructure to make emergency call: Staff conducting 1 to 1 observations upon a patient within the seclusion room were unable to make a direct 999 emergency call from the observation room, as no outside line was available from this handset to respond to a medical emergency. Immediately following the conclusion of the inquest, an adjustment was made to the internal phone line in the observation room in question at Antelope House, allowing external calls. In order to provide further assurance, we have also checked our other inpatient Mental Health units (where there are seclusion rooms) to ensure that they are unimpeded in being able to dial 999 in an emergency situation. Matter of Concern 2: Difficulty in access to ward by South Central Ambulance Service: Secondly, I heard evidence from Paramedics of a delay, and difficulty with accessing the patient, who was being cared for in seclusion. The most immediate access route to the ward used by secure transport services being unknown by South Central Ambulance Service (SCAS), and not shared with them to assist in responding to a medical emergency at Antelope House. Our Legal Services Manager has met with her equivalent at South Central Ambulance Service to agree a process for updating the SCAS Computer Aided Dispatch (CAD) system used by SCAS staff in directing paramedics to a location. A list of all Trust inpatient units has been provided to SCAS, along with the most appropriate location, in the event of an emergency, for the ambulance service to meet our staff. Hampshire and Isle of Wight Healthcare NHS Foundation Trust Headquarters Sterne 7, Tatchbury Mount, Calmore, SO40 2RZ Telephone: 023 8231 0000 | Website: www.hiowhealthcare.nhs.uk In all cases, the ambulance service will be met by a member of our staff and taken to the location of the emergency. We will update this information with our SCAS colleagues on an annual basis, or more frequently if additional inpatient units are added to the Trust’s services. I hope this update assists, should you have any further questions please do not hesitate to contact me. Yours sincerely Executive Chief Medical Officer HIOW Healthcare NHS Foundation Trust
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