Prevention of Future Deaths reports · 2024
Regulation 28 report to prevent future deaths, reference 2024-0705, written 20 Dec 2024. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 20 Dec 2024 |
|---|---|
| Reference | 2024-0705 |
| Deceased | Eleanor Curley-Bennett |
| Coroner | Emma Serrano |
| Coroner area | Staffordshire |
| 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.
REGULATION 28: REPORT TO PREVENT FUTURE DEATHS REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: 1. Festimed – Event Medical Provision Company. 1 CORONER I am Emma Serrano, Acting Senior Coroner of Staffordshire. 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 20 August 2023, I commenced an investigation into the death of Eleanor Curley- Bennett. The investigation concluded at the end of the inquest on 9 December 2024. The conclusion of the inquest was a narrative conclusion. The cause of death was: 1a) Positional Asphyxia 4 CIRCUMSTANCES OF THE DEATH i) Eleanor Curley-Bennett, 3 weeks old, was in a baby carrier with her mother, on the 18 Augusdt 2023. She was at a local, family friendly, music festival. Her mother realised something was wrong and that Eleanor Curley-Bennett, has stopped breathing. ii) She was taken to Festimed, who provided medical care for the music festival. The carried out basic life support on Eleanor Curley-Bennett, before ad during the ambulance journey to the Princess Royal Hospital, Shropshire, where she passed away in the early hours of the morning the following day, the 19 August 2023. iii) During evidence it was disclosed that Festimed did not carry the correct basic life support equipment, in the correct sizing for a baby of Eleanor Curley-Bennet’s age. Specifically. a) oropharyngeal airway; b) i-gel airway; and c) Tracheal tube. It was disclosed that there was no intubation equipment available. It was disclosed that there were no prefilled, diluted, adrenaline that would be suitable to be used on a patient of Eleanor Curley Bennetts age. 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 will occur unless action is taken. In the circumstances it is my statutory duty to report to you. 1 [IL1: PROTECT] The MATTERS OF CONCERN are as follows. – 1. The lack of availability of the equipment and adrenaline described above 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you 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 7 February 2025. 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 family of Eleanor Curley-Bennett. 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 20 December 2024 Miss Emma Serrano Acting Senior Coroner Staffordshire 2 [IL1: PROTECT]
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.
HSCA Further Information Citygate Gallowgate Newcastle upon Tyne NE1 4PA Telephone: 03000 616161 Fax: 03000 616171 Emma Serrano Acting Senior Coroner of Staffordshire. Staffordshire and Stoke on Trent Coroners Service Stoke Town Hall Stoke on Trent ST4 1HH 11 June 2025 Care Quality Commission Our Reference: Dear Emma Serrano Prevention of future death report following inquest into the death of Eleanor Curley- Bennett. Thank you for sending CQC a copy of the prevention of future death report issued following the sad death of Eleanor Curley-Bennett. CQC would like to take this opportunity to offer our sincere condolences to Eleanor’s family. We note the legal requirement upon CQC to respond to your report within 28 working days, 28 April 2025. We would like to thank you for agreeing to an extension for response until 23 June 2025. We note the legal requirement upon Festimed Ltd to respond to your report within 56 days of the report. We note your concerns that you require a response to are about the 9002252 Handling a Regulation 28 Report JLA v2 1 lack of availability of the appropriate equipment and adrenaline to safety treat a baby the age of Eleanor. We also note that Festimed have not responded to the report. We understand that Festimed Ltd provided care and treatment to Eleanor Curley- Bennett both at the festival event site and in their ambulance during conveyance to Telford Hospital. CQC’s regulatory powers do not include care and treatment provided at event work. We do not regulate services, including ambulance providers, who provide a service at events. This meant the care and treatment given by Festimed Ltd to Eleanor at the festival site was not regulated by CQC. CQC can only regulate the service once the ambulance leaves the event (festival site). We are unable to comment on this aspect due to it being outside of our regulatory remit/scope and note that Festimed was the original sole Respondent who would have been in a better position to respond to the concerns whilst on site. This meant only the care and treatment provided by Festimed Ltd to Eleanor in the ambulance once it had left the festival site, was in scope for regulation by CQC. The Government has committed to bring healthcare and treatment delivered at events into scope and CQC is working in close liaison with colleagues at DHSC to remove exemptions to make this happen. The timescales for the new regulations coming into effect are yet to be confirmed, but current indications are that providers will be able to start submitting registration applications at some point in 2026, with the new regulations coming into effect for the purposes of assessment and enforcement at some point in 2027. Until that time, CQC does not have the legal power to regulate activities at events. We have noted your concerns about the lack of availability of the appropriate equipment and adrenaline to safety treat a baby the age of Eleanor. We have not been able to get any assurance from this provider about the actions they have taken to prevent a future death. The actions we have taken to try to get assurance are detailed below. Festimed Ltd notified CQC about the death of Eleanor in August 2023. The registered manager of Festimed Ltd informed CQC in August 2023 that once completed he would share the report and findings from his investigation into the events surrounding the death of Eleanor. In September and October 2024 CQC contacted the registered manager of Festimed Ltd for an update on action taken following the investigation of Eleanor’s death. The registered manager did not respond to the request. We initially became aware of the prevention of future death report on 31 December 2024, following review of the Courts and Tribunals Judiciary website. We noted the legal requirement for Festimed Ltd to respond to your report within 56 days. On 3 January 2025 we wrote to Festimed Ltd again, requesting written confirmation and evidence of the action they had taken to date following this death and any additional action they intended to take in response to the prevention of future death report. Festimed Ltd did not respond. On 3 February we wrote to Festimed Ltd again, in a section 64 letter, requiring them to provide the above information. This letter was sent by email, following 9002252 Handling a Regulation 28 Report JLA v2 2 which we received this message, “Delivery has failed to these recipients or groups.” On 4 and 5 February 2025 we called the Festimed Ltd telephone number which did not connect. We called the telephone number for Festimed Ltd’s registered manager which went straight to voice mail on both occasions. We left a voice mail message asking him to contact CQC. He did not respond or contact CQC. On 7 February 2025 we sent the same section 64 letter by recorded delivery. This was returned to CQC by Royal Mail on 14 February 2025 with the detail the letter could not be signed for because the addressee had gone away. We also reviewed Festimed Ltd details on Companies House and identified they had gone into voluntary liquidation on 12 February 2025 and our understanding is that they are no longer providing a service. We can confirm that since Festimed Ltd was registered with CQC in 2014 our registration processes have been reviewed, with more supporting information and policies now assessed at the time of registration. This will assess potential providers commitment to providing equipment to meet the needs of all people they intend to provide a service to. We appreciate HMC raising the concerns us. We can confirm that CQC is working in close liaison with colleagues at DHSC to remove exemptions to allow CQC to regulate services providing care and treatment. Please contact CQC if you require any further information/assistance. Yours sincerely Deputy Director 9002252 Handling a Regulation 28 Report JLA v2 3
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