Prevention of Future Deaths reports · 2025
Regulation 28 report to prevent future deaths, reference 2025-0418, written 7 Aug 2025. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 7 Aug 2025 |
|---|---|
| Reference | 2025-0418 |
| Deceased | Victor Hutchens |
| Coroner | Rebecca Sutton |
| Coroner area | County Durham and Darlington |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| Organisation named | County Durham and Darlington NHS Foundation Trust |
| 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 NOTE: This form is to be used after an inquest. REGULATION 28 REPORT TO PREVENT DEATHS THIS REPORT IS BEING SENT TO: 1 Chief Executive - County Durham & Darlington NHS Foundation Trust 1 CORONER I am Rebecca SUTTON, Assistant Coroner for the coroner area of County Durham and Darlington 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 03/03/2025 16:39an investigation was commenced into the death of Victor Jackson HUTCHENS 17/05/1939. The investigation concluded at the end of the inquest on 23/07/2025 12:50. The conclusion of the inquest was that On 27 February 2025 at the Darlington Memorial Hospital the deceased died as a result of an accidental fall. On 20 February 2025 the frequency of care rounds provided to the deceased was reduced, in error, from hourly to four-hourly. It cannot be said, on a balance of probabilities, that the error contributed to the deceased’s death. 4 CIRCUMSTANCES OF THE DEATH The deceased died due to a head injury, caused by an accidental fall in hospital. 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: On 20 February 2025, a week before the deceased's death, the frequency of care rounds was reduced, in error, from hourly to four-hourly. The member of staff responsible for the error is unaware of how the error occurred. That being the case, there is a concern that the error could occur again and could cause or contribute to a future death. 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 October 02, 2025. I, the coroner, may extend the period. Your response must contain details of action taken or proposed to be taken, setting out the Regulation 28 – After Inquest Document Template Updated 30/07/2021 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 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: 07/08/2025 Rebecca SUTTON Assistant Coroner for County Durham and Darlington Regulation 28 – After Inquest Document Template Updated 30/07/2021
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.
Executive Corridor Darlington Memorial Hospital Hollyhurst Road Darlington, DL3 6HX E-mail: kburn@nhs.net / j.cundall@nhs.net Our Ref: VHUTCHENSINQ2130 24th September 2025 Rebecca Sutton, Assistant HM Coroner, County Durham Dear Ms Sutton, Re: Victor Hutchens We are writing in response to your request for the Trust to take action in relation to the frequency of care rounds. The frequency was reduced in Mr Hutchens care, in error, from hourly to four-hourly. The member of staff responsible for the error advised they were unaware of how the error occurred. You were concerned that with that being the case, the error could occur again and could cause or contribute to a future death. The Trust would like to offer, once again, its sincere condolences to Mr Hutchens family for their loss. We take very seriously the concerns which you have raised. Following further exploration of the issue, we have identified that the reduction in care rounding was made in error. This decision stemmed from a misunderstanding, where staff believed they were adjusting the frequency of patient observations rather than the care rounding schedule. In response, we have undertaken a comprehensive education programme with the ward team to clarify the distinct purposes of care rounding and observation frequency, and to reinforce that neither should be reduced without appropriate clinical justification and oversight. We have also conducted an organisation-wide audit to ensure this issue is not occurring elsewhere. Where similar practices have been identified, remedial education has been undertaken with the relevant teams. We continue to audit regularly to ensure that correct practices are maintained and embedded across all areas. Please let us know if any further information is required. Yours sincerely Kathryn Burn Executive Director of Nursing Jeremy Cundall Executive Medical Director cc. Mrs. S. Jacques, CEO Mrs L. Ward, Associate Director of Nursing, Patient Safety and CNIO
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