Prevention of Future Deaths reports · 2018
Regulation 28 report to prevent future deaths, written 26 Jan 2018. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 26 Jan 2018 |
|---|---|
| Deceased | Andrew Finlay |
| Coroner | Derek Winter |
| Coroner area | Sunderland |
| Category | Community health care and emergency services related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | none published |
Text recovered by OCR from a scanned PDF. OCR is imperfect: check anything you rely on against the source PDF. Reproduced verbatim, including the scan's own layout.
Derek Winter DL Senior Coroner for the City of Sunderland REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: - Ms Yvonne Ormston Chief Executive North East Ambulance Service NHS Foundation Trust CORONER I am Derek Winter DL, Senior Coroner for the City of Sunderland 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 INVESTIGATION and INQUEST On 14" December 2016 Mr Andrew Stephen Finlay, aged 54 years, died at his home address. The Inquest, as part of my Investigation, concluded on 25"" January 2018, when I recorded a conclusion of Natural Causes. The Cause of Death following Post-Mortem Examination was: - la Myocardial Infarction Ib Coronary Artery Thrombosis Ic Coronary Artery Atheroma II Hypertension CIRCUMSTANCES OF THE DEATH Andrew Stephen Finlay, known in the Inquest as Andrew, aged 54 years, collapsed at his home address on 13"" December 2016. Andrew’s partner telephoned 999 from their home address requesting an emergency ambulance. The call was graded as a Red 2 response. The normal response time for this category of call is 8 minutes. Despite further telephone calls, it took an ambulance crew in the region of 36 minutes to arrive. Expert evidence from a Consultant in Emergency Medicine and a Consultant Cardiologist was such that delays in the despatch and arrival of an ambulance crew did not affect the outcome. It was more likely than not that Andrew would have died in any event. Civic Centre, Burdon Road,Sunderland, SR2 7DN Tel 0191 5617843 | Fax 01915537803 | DX 60729 Sunderland www.sunderland.gov.uk/coroner CORONER’S CONCERNS Inquests are a fact finding inquiry into a person’s death and it is important that lessons are learnt. The making of this report is not punitive nor is it a censure. However, it is the 2"’ such Report in recent months that I have written about the timely despatch and arrival of an ambulance crew in response to a 999 call. I heard evidence about the reviews of procedures undertaken since Andrew’s death, but I still have concerns. Although the plans for the recruitment and retention of personnel and the purchase of additional vehicles were encouraging to hear evidence about, I was told there were still 32 paramedic vacancies to be filled a year on after Andrew’s death. For Andrew the delay made no difference, but for someone else it might. Accordingly it is my duty to write this Report to you, particularly as it may add impetus to the improvement plan. 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. YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 27" March 2018. 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 the Chief Coroner and to the following: - . Family and their Solicitors Secretary of State for Health Head of Risk — Quality and Safety, North East Ambulance Service NHS Foundation Trust and Trust’s Counsel/Solicitors Care Quality Commission (CQC) Healthcare Safety Investigation Branch (HSIB) 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. Dated this 26" day of January 2018 Signature Q A ra Senior Coroner for the City of Sunderland
See every Prevention of Future Deaths report matching Community health care and emergency services related deaths, and how often a new one appears.
What would an alert for this have sent me? Search the full text
Free to try — the preview shows the real matches and how many arrived in the last 12 months. Your first email alert is free.
These reports are published by the Chief Coroner's office at judiciary.uk and are © Crown copyright. The text here is reproduced from the published PDF so it can be searched. If something on this page is wrong, or you are a person named in it and want it reviewed, email drcjar@gmail.com and we will act promptly.