Prevention of Future Deaths reports · 2015
Regulation 28 report to prevent future deaths, written 1 Sep 2015. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 1 Sep 2015 |
|---|---|
| Deceased | John Robinson |
| Coroner | David Urpeth |
| Coroner area | South Yorkshire (West) |
| 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.
REGULATION 28: REPORT TO PREVENT FUTURE DEATHS (1)
REGULATION 28 REPORT TO PREVENT FUTURE DEATHS
THIS REPORT IS BEING SENT TO:
1. Clinicat Commissioning Group
4 | CORONER
David Urpeth, Assistant Coroner, South Yorkshire (West)
2 | CORONER’S LEGAL POWERS
| 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.
(1) Where -
(a) Asenior coroner has been conducting an investigation under this Part
into a person's death
(b). Anything revealed by the investigation gives rise to a concern that
circumstances creating a risk of other deaths will occur, or will continue to
exist, in the future, and
{c) In the coroner’s opinion, action should be taken to prevent the occurrence or
continuation of such circumstances, or to eliminate or reduce the risk of death
created by such circumstances, the coroner must report the matter to a
person who the coroner believes may have power to take such action.
(2) Apperson to whom a senior coroner makes a report under this paragraph must
give the senior coroner a written response to it.
(3) Accopy of a report under this paragraph, and of the response to it, must be sent to
the Chief Coroner
INVESTIGATION and INQUEST
On 22™ May 2015 | commenced an investigation into the death of John Henry Robinson
(aged 84). The investigation concluded at the end of the inquest on 21“ August 2015.
The narrative conclusion of the inquest was that:
On 21" April 2015, Mr Robinson went into Broomcroft House Nursing Home for respite
care. It was subsequently recognised that he required admission to a Psychiatric bed
but no suitable bed was available. On 9" May 2015 Mr Robinson was admitted to the
Northern General Hospital, Sheffield where he remained until his death on 18" May
2015.
The medical cause of death was found to be;
1(a) Acute Kidney injury
1(b) Dehydration
1(c) Severe Depression
2 Dementia, Chronic Kidney Disease, ischaemic Heart Disease and Diabetes
CIRCUMSTANCES OF THE DEATH
On 21* April 2015, Mr Robinson went into Broomcroft House Nursing Home for respite
care. It was subsequently recognised that he required admission to a Psychiatric bed
but no suitable bed was available. On 9" May 2015 Mr Robinson was admitted to the
Northern General Hospital, Sheffield where he remained until his death on 18" May
2015.
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.
The MATTERS OF CONCERN are as follows. —
The evidence at inquest suggested Mr Robinson required a psychiatric bed on
Dovedale, but no such bed was available.
His condition deteriorated and he ultimately died.
The concern is whether sufficient resources are available in this area.
ACTION SHOULD BE TAKEN
In my opinion action should be taken to prevent future deaths and | believe your
organisation has 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 Wednesday, 18" November 2015. | 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
| have sent a copy of my report to the Chief Coroner and to the following Interested
Persons (who are not under a duty to respond):
L___{G)
family)
HE Clinical Commissioning Group)
fam 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.
1™ September 2015 David Urpeth
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