Prevention of Future Deaths reports · 2015
Regulation 28 report to prevent future deaths, written 11 Dec 2015. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 11 Dec 2015 |
|---|---|
| Deceased | Margaret O’Brien |
| Coroner | Chinyere Inyama |
| Coroner area | London (West) |
| Category | Care Home Health 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) NOTE: This form is to be used after an inquest. REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: CARE UK, HAWKER HOUSE, 5-6 NAPIER COURT, NAPIER ROAD, READING, BERKSHIRE RG1 8BW 1 CORONER | am Chinyere Inyama, senior coroner for the coroner area of West London 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. 3 | INVESTIGATION and INQUEST On 22nd March 2014 | commenced an investigation into the death of Margaret O'Brien age 65. The investigation concluded at the end of the inquest on 30" September 2015. The conclusion of the inquest was that Ms O'Brien died from natural causes.. 4 | CIRCUMSTANCES OF THE DEATH The deceased was discovered unresponsive in her bed at the care home where she resided in having shown signs of a cold the previous evening. 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. The MATTERS OF CONCERN are as follows. — There appeared to be an absence of specific, prescribed training of staff on how to carry out and record observations of residents. 6 | ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and | believe you and 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 5" February 2016. |, 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. 8 | COPIES and PUBLICATION ] | have sent a copy of my report to the Chief Coroner and to the following persons: daughters of the deceased), Stephenson's Solicitors (legal representatives iE! Clyde & Co (legal representatives of Care UK). | 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. “1 41™ December 2015 SIGNED BY CORONER Cheyne
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