Four years of published coroners_ Section 28 reports to ... · prevent future deaths in England and Wales ... Database of 4 years of coroners’ Section 28 warning reports, published

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Fouryearsofpublishedcoroners’Section28reportsonactiontopreventfuturedeathsinEnglandandWalesDrMinhAlexanderNHSwhistleblowerandformerconsultantpsychiatrist24August2017Contact:@alexander_minhandviaminhalexander.comContents PAGESummary Page1Introduction–coroners’warningreportsandpastfailuresoflearning

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Databaseof4yearsofcoroners’Section28warningreports,publishedupto31July2017

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Generalresults Page12NumbersofSection28reports Page17Austerityanddecency Page19Coroners’firesafetywarningsbeforeGrenfell Page21NHSsafety Page26Proportionofcoroners’warningsabouttheNHS Page23Coroners’warningsaboutambulanceservicesandrelatedmatters Page32Conclusion Page48Appendix–PresscriticismofCQCfailuretoactuponcoroners’warningsandCQCresponseSeptember2015

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SUMMARYIntherecentyearsofausterity,thegovernmenthasrunanexplicitlyanti-redtapeprogramme,purportedlybusinessfriendlybutopenlyhostileto‘HealthandSafety’regulations.12

1In2012DavidCameronPMreportedlystatedthathewould“killoffthehealthandsafetycultureforgood”http://www.independent.co.uk/news/uk/politics/david-cameron-i-will-kill-off-safety-culture-6285238.html2CabinetOffice‘Cuttingredtapeprogramme’https://cutting-red-tape.cabinetoffice.gov.uk/

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Thispapersharesadatabasecollatedfromfouryearsofcoroners’Section28warningreportsaboutpublicsafetythathavebeenpublishedbythechiefcoroner,andabroadinitialreportaboutthedata.AlthoughitispositivethatSection28reportshavebeenpublishedinrecentyears,Icollatedthisdatabecausethechiefcoroners’websiteisnotsearchableanddoesnotgivethepublicaccesssufficient,meaningfulaccesstoSection28reports.Patternsarefurtherobscuredbyinconsistentindexingofcases.Somenotableinstancesofmiscategorisationofimportantcaseswerefound(forexamplesuicides,policerelateddeaths,deathsincustody,deathsofarmedforcespersonnel).Questionsalsoariseaboutthecompletenessofthedatareleased.Itisverylikelythatanumberofreportshavenotbeenpublished.Ofthedatathatexists:

• Atleast57.2%(987of1725)ofpublishedSection28reportsrelatedtopoorNHScareandhazards.

• SeventySection28reportsrelatedtodeathsinthecustodyoftheState

• 350Section28reportsrelatedtoselfinflicteddeaths,whetherthrough

misadventureorbysuicide.

• 60Section28reportswereaboutdeathswheretherehadbeenneglect,includingeightdeathsinStatecustody.

• Themajorityofthe‘neglectcases’wereaccountedforbytheNHS.

Therewerenopublishedresponsesatallto62%(1070of1725)ofSection28reportsbyorganisationsandpersonswhohadbeensentthemforactiontopreventfuturedeaths.Moreover,noexplanationisprovidedforthisbythechiefcoroner’soffice.ThepaucityofpublishedresponsesisunexpectedbecausepastgovernmentrecordsshowedthevastmajorityoforganisationspreviouslyrespondedtoRule43reports,whichwerethepredecessortoSection28reports.ClarificationisneededonwhetherresponserateshavedeterioratedandorwhethertheChiefCoronerischoosingnottopublishresponses.Thelackofpublishedresponsestocoroners’warningsraisesquestionsaboutwhethertheauditcycleisbeingclosedandthereforetheeffectivenessofpublicprotection.TheGrenfellfirebeingthemostpainfulillustrationpossibleoftheconsequencesofsuchfailure.Relevanttofiresafety,thereweretwentypublishedSection28reportsinthelastfouryearsrelatingtofiresafety,includingrecommendationsforinstalmentoffiresprinklersandalarmsinsocialhousing,andtheneedtoinvestigatetheuseofflammableinsulatingmaterialinHotpointfridgefreezerswhichcanactasanaccelerant.

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InrelationtoNHScases,notwithstandingthelimitationsofthecoroners’data,anumberofrecurringthemesareevident,raisingquestionsaboutorganisationallearning.Coronershighlightedalackofresourcesinanumberofimportantcases,someacute.Ofgreatconcerntopublicsafety,itisalsoclearthatcoronershavebeenseriouslyconcernedforseveralyearsaboutdeterioratingambulanceresponsesandtheroleofrelatedcallhandlinganddiversionservices.Ambulancedelayshavecostlivesandputthepublicatrisk.TheeffectivenessoftheDepartmentofHealth’sresponsetocoroners’concernsisinquestion.ThecredibilityofCQC’sratingsonambulancetrustsisalsochallengedbytheconcernsthatcoronershavebeenrepeatedlyflagging.CQC’srecentratingofanambulancetrustas‘Outstanding’isespeciallyquestionablewhenallareclearlyoperatinginseverelychallengingconditions.TheseconcernsareunderlinedbythefactthatCoroner’sSection28reportsrepresentonlythetipofasafetyiceberg.Currently,thereisnoevidenceofasystematicgovernmentapproachtolearningfromtheSection28reports.Thereisnopublishedevidenceofcentralanalysis.IhavewrittentoasktheChiefCoronerabout:

• HowmanyoftheSection28reportsissuedsofarhavebeenpublished• MissingresponsesfromrecipientsofSection28reports• Anygovernmentanalysisthatistakingplace• WhathappensifcoronersaredissatisfiedbySection28responses• Possibleimprovementstothewebsiteforgreatertransparency.

TheDepartmentofHealth,NHSregulatorsandotheroversightbodieswillbeaskedabouttheirhandlingofSection28reports.Ishouldbeverygratefulandinterestedtohearfromanyonewhoisawareofcoroners’Section28reportsthathavebeenissuedbuthavenotbeenpublished.INTRODUCTIONCoronershaveadutytoinvestigatecertaindeathsandtodeterminehowthesehappened.ThsesareuptodateHouseofCommonsbriefingsonwhatcoronersandtheChiefCoronerdo:

http://researchbriefings.parliament.uk/ResearchBriefing/Summary/SN03981http://researchbriefings.parliament.uk/ResearchBriefing/Summary/SN05721

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Itisanimperfectsystemandheavilydependentonreporting.Coronersmaymisssalientissues.Powerfulorganisationswithunlimitedfundsforlegalservicesaremoreabletomanipulatethesystem,andbereavedfamiliesmaybedisadvantagedbyinequalityofarms.34Anumberofreformshavebeenintroduced.Debateandevaluationcontinuesonhoweffectivetheseare.56Thereisconsiderableregionalvariationinreportingtocoroners,andvariationbetweenindividualcoroners’departments.7

3Howtheinquestsystemfailsbereavedpeoplehttp://www.inquest.org.uk/pdf/how_the_inquest_system_fails_bereaved_people.pdf4DeathcertificationandinvestigationinEnglandWalesandNorthernIreland.Thereportofafundamentalreview2003.http://webarchive.nationalarchives.gov.uk/20131205105739/http://www.archive2.official-documents.co.uk/document/cm58/5831/5831.pdf5Reformofthecoroners’systemanddeathcertification,ConstitutionalAffairsCommittee,1August2006https://publications.parliament.uk/pa/cm200506/cmselect/cmconst/902/902i.pdf6ImplementingthecoronerreformsinPart1oftheCoronersandJusticeAct2009Responsetoconsultationonrules,regulations,coronerareasandstatutoryguidance.MoJ4July2013https://consult.justice.gov.uk/digital-communications/coroner-reforms/results/implementing-the-coroner-reforms-response.pdf7CoronersStatisticsAnnual2016EnglandandWales“Whenlookingatthenumberofdeathsreportedtocoronersin2016asaproportionofregistereddeaths21,whichallowforsomedifferencesinpopulationcharacteristics,thereisstillawidevariationacrosscoronerarease.g.28%inEastLancashirecomparedto96%inStoke-on-TrentandNorthStaffordshire.”“Theproportionofpost-mortemscarriedoutvariesfrom21%inNorthLincolnshireandGrimsbyto62%inIsleofWight.”“Theproportionofinquestscarriedoutvariesfrom8%inStoke-on-TrentandNorthStaffordshireto40%inNorthTyneside.”https://www.gov.uk/government/statistics/coroners-statistics-2016

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Ofrelevance,anationalnetworkofmedicalexaminerstoimprovescrutinyofdeathsandtodetectpoorcaremorepromptlyhasbeenproposedbyvariouspublicinquiries,andstronglysupportedbytheRoyalCollegeofPathologists.89However,thishasbeenrepeatedlydelayed.Controversially,thegovernmentannouncedafurtherdelayearlierthisyear,withanewimplementationdeadlinesetfor2019.10Nevertheless,forallthelimitations,coroners’findingsprovideanimportantwindowintoriskstopublicsafety.Ofspecialinterestarethewarningreportsthatcoronersissueonanexceptionalbasiswhentheyconsiderthatactionneedstobetakentopreventfuturedeaths.Coronerspreviouslyhaddiscretionarypowerstoissuea‘Rule43’reportundertheCoronersRules1984onmattersarisingfromdeathstheyhadreviewedwhichcouldcausearecurrenceofsimilarfatalities.11

8Anoverviewofthedeathcertificationreforms.DepartmentofHealthMay2016https://www.gov.uk/government/publications/changes-to-the-death-certification-process/an-overview-of-the-death-certification-reforms9MedicalExaminers.RoyalCollegeofPathologists.May2016https://www.rcpath.org/discover-pathology/public-affairs/medical-examiners.html10StatementbyRoyalCollegeofPathologists30March2017inresponsetofurthergovernmentdelayhttps://www.rcpath.org/discover-pathology/news/medical-examiner-delay.html11“43.Acoronerwhobelievesthatactionshouldbetakentopreventtherecurrenceoffatalitiessimilartothatinrespectofwhichtheinquestisbeingheldmayannounceattheinquestthatheisreportingthematterinwritingtothepersonorauthoritywhomayhavepowertotakesuchactionandhemayreportthematteraccordingly.(a)aseniorcoronerhasbeenconductinganinvestigationunderthisPartintoaperson’sdeath,(b)anythingrevealedbytheinvestigationgivesrisetoaconcernthatcircumstancescreatingariskofotherdeathswilloccur,orwillcontinuetoexist,inthefuture,and(c)inthecoroner’sopinion,actionshouldbetakentopreventtheoccurrenceorcontinuationofsuchcircumstances,ortoeliminateorreducetheriskofdeathcreatedbysuchcircumstances,thecoronermustreportthemattertoapersonwhothecoronerbelievesmayhavepowertotakesuchaction.(2)Apersontowhomaseniorcoronermakesareportunderthisparagraphmustgivetheseniorcoronerawrittenresponsetoit.

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ThispowerwasusedvariablyandwasreplacedwithastatutorydutyunderPart7ofSchedule5oftheCoronersandJusticeAct2009.Thisconferredawiderdutytoraiseallmattersdiscoveredduringinvestigationthatcouldpreventafuturerisktolife,whetherornottheyhadcontributedtothedeathinquestion.Suchreportsareknownasreportsonactiontopreventfuturedeaths,or“PFDs”.12OnreceiptofaSection28report,recipientsmustprovidethecoronerwithawrittenresponse,(atimelimitof56daysisgiven),andthecoronermustsendacopyoftheSection28reportandanyresponsestotheChiefCoroner,whomaypublishthem.

(3)Acopyofareportunderthisparagraph,andoftheresponsetoit,mustbesenttotheChiefCoroner.”http://www.legislation.gov.uk/uksi/1984/552/contents/made12CoronersandJusticeAct2009“Actiontopreventotherdeaths7(1)Where—(a)aseniorcoronerhasbeenconductinganinvestigationunderthisPartintoaperson’sdeath,(b)anythingrevealedbytheinvestigationgivesrisetoaconcernthatcircumstancescreatingariskofotherdeathswilloccur,orwillcontinuetoexist,inthefuture,and(c)inthecoroner’sopinion,actionshouldbetakentopreventtheoccurrenceorcontinuationofsuchcircumstances,ortoeliminateorreducetheriskofdeathcreatedbysuchcircumstances,thecoronermustreportthemattertoapersonwhothecoronerbelievesmayhavepowertotakesuchaction.(2)Apersontowhomaseniorcoronermakesareportunderthisparagraphmustgivetheseniorcoronerawrittenresponsetoit.(3)Acopyofareportunderthisparagraph,andoftheresponsetoit,mustbesenttotheChiefCoroner.”http://www.legislation.gov.uk/ukpga/2009/25/pdfs/ukpga_20090025_en.pdf

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RecipientsofSection28reportsareofteninformedthattheymaymakerepresentationstocoronersaboutwhethertheirresponsesarepublished:

AsfarasIcansee,thereisnoprovisionsetoutintheChiefCoroner’sguidance13forcircumstanceswheretherecipientsofSection28reportsfailtorespondtocoroners.Thisseemsasignificantsystemweakness.Itseemsanoddprocessofjusticewherematterscansimplefizzleout,beyondthepubliceye.IcanseenoexplanationfromtheChiefCoroneronhowdecisionsaremadewithregardstowhetherSection28reportsandresponsesarepublishedornotpublished.Again,thisseemsanomissioninthefaceoftheprinciplethatjusticemustbeseentobedone.Section28reportsareissuedonlyinasmallnumberofinquestcases.DuetodatamissingfromtheChiefCoroner’sannualreportsonthenumberofSection28reportsthathavebeenissuedsincetheywereintroduced,itisnotpossibletosaydefinitivelywhatproportionofinquestshavegeneratedSection28reportssincethelatterwereintroducedin2013.

13TheChiefCoroner’sguidetotheCoronersandJusticeAct2009https://www.judiciary.gov.uk/publications/the-chief-coroners-guide-to-the-coroners-and-justice-act-2009/

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However,themostrecentChiefCoroner’sannualreportseemstoindicatethatadecisionwasmadein2015/16tostartpublishingallSection28reports:Year Numberofinquest

conclusionsrecordedChiefCoroner’sannualreportonSection28

reports2013 31,579 2013/14:“Allreports(andresponses)mustnow

besenttotheChiefCoronerandtheyarepublishedonthejudiciarywebsite.Somereportsareselectedtopursuefurther.Allofthatisnew.AndtheChiefCoronerencouragescoronerstowritereports.”Nofiguregiven.

2014 29,153 2014/15:“Sincethepublicationoflastyear’s

ChiefCoroner’sreport504PreventionofFutureDeathreports(paragraph7(1)Schedule5tothe2009Act)havebeenissued.”

2015 35,473 2015/16:“ThesePFDreports-571innumberin

2015-arehugelyimportant.Theydrawattentionofgovernmentagencies,individualsandorganisationstothefactthatsomethinghasgonewrongandactionshouldbetaken…BecauseoftheirimportancetheChiefCoronerdecidedtopublishallPFDreportsonthejudiciarywebsite(sometimeswithredaction).Theyarethereforemadepublicandaccessibletoallwhomayhaveaninterestinthem.Emailalertsarenowavailable.Forexample,NHSEngland(LondonRegion)hasusedthisresourcetoidentifylearningfromthedeathsofvulnerableadultsandchildreninhealthcaresettingsacrossLondon.”

2016 40,504 NodataavailableyetSource:Coroners’annualstatisticsandChiefCoroner’sannualreportstotheLordChancellor14

14Coroners’annualstatisticsandChiefCoronersannualreportshttps://www.gov.uk/government/statistics/coroners-statistics-2013https://www.gov.uk/government/statistics/coroners-statistics-2014https://www.gov.uk/government/statistics/coroners-statistics-2015https://www.gov.uk/government/statistics/coroners-statistics-2016https://www.gov.uk/government/publications/chief-coroners-annual-report-2013-to-2014https://www.gov.uk/government/publications/chief-coroners-annual-report-2014-to-2015https://www.judiciary.gov.uk/publications/chief-coroners-annual-report-2015-16/

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Thereappeartohavebeenlimitedeffortstomakesystematicuseofthedatafromcoroner’swarningreports.TheChiefCoronerpreviouslypublishedperiodicsixmonthlysummariesonRule43reportswhichprovidedbriefsummariesofcoroners’concernsanddetailsofthebodiesinvolved.15AfterthesystemchangedfromRule43reportstoSection28reports,theChiefCoronerpublishedaninitialsummaryreportfortheperiod1April2013to30September2013,butnoothersseemtohavefollowed.

https://minhalexander.files.wordpress.com/2016/09/april-2013-to-september-2013-summaryreportofpfdreportsapr-sep2013-10th.pdf

Icouldfindnoothersignsofrecentanalysis,indepthorotherwise,ofwarningreports.

15MoJSummariesofReportsandResponsesunderRule43oftheCoronersRulesJuly2008toMarch2013https://minhalexander.files.wordpress.com/2016/09/july-2008-to-march-2009-summary-rule-43-v1.pdfhttps://minhalexander.files.wordpress.com/2016/09/april-2009-to-september-summary-rule-43-v2.pdfhttps://minhalexander.files.wordpress.com/2016/09/oct-2009-to-march-2010-third-summary-coroners-reports-rule43a.pdfhttps://minhalexander.files.wordpress.com/2016/09/april-2010-to-oct-2010-rule-43-coroners-report-4th.pdfhttps://minhalexander.files.wordpress.com/2016/09/oct-2010-to-march-2011-summary-rule-43-070312-5th.pdfhttps://minhalexander.files.wordpress.com/2016/09/april-2011-to-september-2010-summary-rule-43-6th.pdfhttps://minhalexander.files.wordpress.com/2016/09/oct-2011-to-march-2012-summary-rule-43-v7.pdfhttps://minhalexander.files.wordpress.com/2016/09/april-2012-to-sept-2012-summary-rule-43-report-v8.pdfhttps://minhalexander.files.wordpress.com/2016/09/oct-2012-march-2013-9th-rule-43-report.pdf

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ThecharityINQUEST,inparticular,hasbeencriticaloftheresistancetolearningfromdeathsincustodyandmentalhealthdeaths,inwhichthesamegrievouserrorsareendlesslyrepeateddespiteveryspecificcoroners’warnings.16ThereisalsoaquestionofwhathappenswhencoronersaredissatisfiedwiththeresponsesthattheyreceivetotheirSection28reports.Itappearsthatthetrailendsuntilthenextsimilardeath,whenthecoronermakesreferencetothepasthistoryandprevioussimilardeaths.DATABASEOF4YEARSOFCORONERS’SECTION28WARNINGSPUBLISHEDUPTO31July2017SinceJuly2013allSection28reportshadtobesenttotheChiefCoronerforpossiblepublication.PublicationbeganinJanuary2014whenthethenChiefCoronerPeterThorntonreportedlyemphasisedtheimportanceoftransparency:“Iplacegreatemphasisonthevaluableworkofcoronersinsavinglivesbyhighlightingriskswhichneedtobeeliminated.Thatiswhypublishingthesereportsandputtingthemintothepublicdomainissoimportant.”17Ihavebeenfollowingthechiefcoroner’spublicationofSection28reportsforthelastyear.Ihavefoundthatreports,andresponsestothereports,areuploadedsomewhaterratically,sometimeswithvariabledelaysofmonths.Asnapshottakenatanypointintimeislikelytobeasignificantunderestimateofthereportsthatexist.IhaveloggeddetailsofallpublishedSection28reportsuptoof31July2017ontothisdownloadabledatabase:

https://minhalexander.files.wordpress.com/2017/08/all-section-28-reports-on-action-to-prevent-future-deaths-published-by-chief-coroner-up-to-31-july-2017-pub.xlsx

Thedatabaseprovideslinkstotheindividualpublishedreportsandanyassociatedresponsesbypersonstowhomthereportsweresent.Namesofdeceased,coroner’scasereferencenumbers,coroners’categoriesofdeathandcoroners’areasarealsoprovided.Thisdatacanbesearched.

16http://inquest.org.uk/pdf/INQUEST_deaths_in_mental_health_detention_Feb_2015.pdfhttp://www.inquest.org.uk/pdf/reports/Learning_from_Death_in_Custody_Inquests.pdf17https://www.crimeline.info/news/publication-of-reports-to-prevent-future-deaths

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IhavefoundtheChiefCoroner’swebsiteuserun-friendlyforthefollowingreasons:

• Thewebsiteisnotsearchable,unlikecomparablewebsitesoperatedbytheCourtsandTribunalsJudiciary

• Pagesmustbescrolledlaboriouslyandslowly.Losingone’splacerequiresstartingagainfromsquareone,makingsearchesagargantuantask.

• Itprovidesaflawedandmisleadingsystemofindexingwhereusersaresignpostedtocategoriesofdeathwhichareinfactincomplete,becausesomecasesarenotcorrectedlabelledandrelevantcasesaredispersedthroughoutotherdifferentcategories.

Forexample,therewere94Section28reportsaboutdeathsdeterminedtobesuicides,butoverhalfofthese(54)werenotlabelledassuchontheChiefCoroner’swebsite.Theywouldhavebeenmissedbyanymemberofthepubliclookingfordeathsbysuicide,unlesstheysystematicallyscrolledthroughthewholedatabase.

Forexample,amuchreportedandimportantSection28reportonaDWPrelatedsuicide,thedeathofMichaelO’Sullivan,wasfiledunder‘Otherrelateddeaths’:

“CIRCUMSTANCESOFTHEDEATHIfoundthatthetriggerforMrO’Sullivan’ssuicidewashisrecentassessmentbyaDWPdoctorasbeingfitforwork.”https://www.judiciary.gov.uk/publications/michael-osullivan/

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Thiscaseandafewothermislabelledsuicidescouldbeaccountedforbythefactthatthecategoryof‘suicide’wasnotintroducedbythechiefcoroner’sofficeuntil2015.However,thisdoesnotaccountformanymislabelledSection28reportswhichwereissuedin2015andafter.Conversely,afewdeathswerelabelledassuicideswhentheSection28reportsgavenoindicationofspecificintentorevenexplicitlystatedthatnospecificintenthadbeenproven.ThisisthelistofpublishedSection28reportsonsuicides,showingwhichreportswerecorrectlylabelledandwhichwereobscured:https://minhalexander.files.wordpress.com/2016/09/section-28-reports-on-deaths-by-suicide-published-by-chief-coroner-up-to-31-july-2017.xlsx

Inadditiontosuicides,otherimportantexamplesofmislabelleddeathsincludeddeathsincustody,policerelateddeaths,servicepersonneldeathsandconstructionindustrydeaths.18

Initscurrentstate,theChiefCoroner’swebsiteisnotsufficientlyaccessibletothepublic.Thisisbecauseitdoesnotallowinterrogationwithoutextraordinaryusereffort,thereisobfuscationoftrendsandsystemicrisksbecauseofthewaydataispresented.Thereisariskthatbereavedfamiliesmaybedeniedanswers.Makingthewebsitesearchable,includingbyfreetextandbydifferentparameterssuchasdates,namesofdeceased,namesofcoroner,coronerareaandcategoryofdeathswouldincreaseaccessibilityandtransparency.GENERALRESULTSIfoundatotalof1725Section28reportsbycoronersinEnglandandWalespublishedupto31July2017,relatingtothedeathsof1799people.Theearliestofthereportshadbeenissuedon30July2013.TheSection28reportsrelatedtothedeathsofatleast1142malesand646females(dataongenderwasmissinginafewcases).

18Examplesofimportantcasesthatweremislabelledorincompletelycrossreferencedincluded:Duggan2014-0182filedunder‘Otherrelateddeaths’,Cunningham2014-0087filedunder‘Productrelateddeaths’,Overy2014-0535filedunder‘Otherrelateddeaths’,Dalrymple2014-0410filedunder‘Otherrelateddeaths’McGlasson2014-0001aconstructionindustrydeathfiledunder‘Alcohol,drugandmedicationrelateddeaths”

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Thereatleast175childdeaths(definedasagebeloweighteen).Atleast350Section28reportsrelatedtoself-inflicteddeaths18b,withaspecificfindingofsuicideindicatedin94ofthereports.70ofthepublishedSection28reportsrelatedtodeathsinStatecustody,whichoccurredmostlyinprisonsbutalsoinpolicecustody,immigrationcentresandsecurepsychiatricunits.60ofthepublishedSection28reportsrelatedtocasesinwhichinquestshadmadefindingsofneglect,althoughinonecaseneglectwasnotedbutwasnotconsideredtohavecontributedtothedeath.Onecaseofneglect,thedeathofIvyAtkinacarehomeresident,wassogrossthataninquestmadeafindingofunlawfulkilling.Shereportedlylostalmosthalfherbodyweightin48daysandwasdiscoveredclosetodeathwithaninfectedpressuresore.Therewasanaccompanyingcriminalconvictionofmanslaughteragainstthecarehomeowner.Theregulator,CQC,wascriticisedforfailings.19Shamefully,eightofthepublished60casesofneglect(13.3%)relatedtoStatedetention.Fouroutofeightofthesecustodycasesprimarilyinvolvedprivateproviders.20

18bIhaveusedtheclassificationofselfinflicteddeath,asusedforcustodydeaths,whichencompassesbothdeathsinwhichintentofsuicideisclearbeyondreasonabledoubtandotherinstanceswherepeoplediedbytheirownhandsbutdefinitesuicidalintentwasnotfound,orwhererecklessnessandmisadventurewereconsideredtobemorelikely.19Nottinghamcarehomebossjailedformanslaughter,BBC6February2016http://www.bbc.co.uk/news/uk-england-nottinghamshire-3549986520Custodydeathswithneglectfindings-casereferencedetails:Thedetainedpatientsdiedinprison,animmigrationcentre,undertheMentalHealthActandDeprivationofLibertySafeguards.PeterBarnesCygnetHospitalRef.2013-0291,ShalaneBlackwoodHMPNottinghamRef.2016–0179,KingsleyBurrellBirminghamandSolihullMentalHealthNHSTrustRef.2015-0472,BrianDalrympleHarmondsworthImmigrationRemovalCentreGEOGroupUKLtd(formerlyG4S)Ref.2014-0410,DaleProverbsMHAPartnershipsinCareRef.2015-0010,ChristopherRoyalBaron’sParkNursingHomeRef.2014-0354,DeanSaundersHMPChelmsfordRef.2017-0056,RichardWalshHMPBelmarshRef.2016-0377

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ThebulkoftheneglectcasesrelatedtotheNHS.Therewereanumberof‘repeatoffender’trusts.PennineAcuteNHSTrustreceivedfourSection28reportsindeathswheretherehadbeenafindingofaneglect.21Thisisthefulllistofthe60publishedcaseswhereneglecthadbeenfound:

https://minhalexander.files.wordpress.com/2016/09/section-28-reports-with-findings-of-neglect-published-up-to-31-july-20171.xlsx

ResponsesTherewerenopublishedresponsesatallto1070ofthe1725(62%)coroners’Section28reports.Therewerenopublishedresponsesfor43ofthe70(61%)section28reportsondeathsinStatecustody,whenonemightimaginethatthisisakeyareaforaccountabilityandtransparency.Therewerealsonopublishedresponsesto32ofthe60(53.3%)Section28reportsondeathswereafindingofneglecthadbeenmade.Whereresponseswerepublished,therewasnotalwaysafullsetofresponsesfromallthepartieswhohadbeensentSection28reportsasanamedrespondentforactiontopreventfuturedeath.Particularlyworryingwasalackofconsistentpublishedresponsesbygovernmentdepartmentsandoversightbodies.Forexample,therenoresponsesto60outof172Section28reportssenttotheDepartmentofHealthforactiontopreventfuturedeaths.Therewerenoresponsesto45outof100Section28sentpersonallytotheSecretaryofStateforHealthforactiontopreventfuturedeaths.Wethereforedonotknowwhataction,ifany,JeremyHuntproposedtotakeinresponsematterssuchas:

- ConcernsaboutcontinuingNeverEventsandpoorgovernanceatNorthCumbriaUniversityHospitalsNHSTrust,oneoftheso-called14‘Keogh’trusts

21PennineAcuteHospitalNHSTrustdeathswithfindingsofneglect:Ref.2017-0063,ColinMoulton10July2015Ref.2015-0267,DominicSmith30June2016Ref.2016-0240,MillyZemmel6April2016Ref.2016–0139,Ref2014-0421,KathleenCooper8March2017

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https://www.judiciary.gov.uk/publications/amanda-coulthard/

- ConcernsaboutrisktolifefromanationalshortageofradiologistsSection28report,Ref.2016-0491,12May2016ondeathofConstancePridmoreunderthecareofUniversityHospitalsofMorecambeBayNHSFoundationTrust:

“…presentlythereare400vacantunfilledconsultantradiologistpostsunfilledintheUK…Itisprobablethatcurrentdelaysonbothalocalandnationalbasisinobtaininginatimelymanner,accurateradiologistreportsofx-raysandCTscanstakenfordiagnosticpurposes,createsaforeseeableriskthatfurtherdeathsmaywellariseasaconsequence.”

https://www.judiciary.gov.uk/wp-content/uploads/2014/11/Nelson-2014-0397.pdfhttps://www.judiciary.gov.uk/wp-content/uploads/2017/03/Pridmore-2016-0491.pdf

- Concernsaboutrisktolifefromflawedambulancecallhandlingandalgorithmshttps://www.judiciary.gov.uk/publications/keith-ruston/https://www.judiciary.gov.uk/wp-content/uploads/2015/07/Lester-2015-2015-0204.pdf

- Concernsaboutrisktolifefrompersistentlackofacutementalhealthbeds

https://www.judiciary.gov.uk/publications/george-taylor/

- Concernsaboutrisktolifefromlackofpatienteducationaboutinsulinpumpshttps://www.judiciary.gov.uk/wp-content/uploads/2017/02/Thornton-2017-0030-1.pdf

Moreover,coronerssent47Section28reportstothehealthandsocialcarewatchdog,theCareQualityCommission(CQC)foractiontopreventfuturedeaths,buttherewerenopublishedresponsesbyCQCto33ofthesereports[seesheet2ofthemaindatabase],eightofwhichrelatedtodeathsinwhichafindingofneglecthadbeenmade.22

22Section28reportssenttoCQCforactiontopreventfuturedeath,incaseswheretherehadbeenafindingofneglect,withnopublishedCQCresponsetothecoroner:

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TheCQCisinfactaspecialcasebecauseithasamemorandumofunderstandingwiththeCoroners’Society23whichensuresthatitreceivescopiesofallSection28reports,andisthustheoreticallyinapositiontotrackandactupontheintelligencethatcoronersprovide.TherearesignsthattheCQCfailstodosoandisnotopenaboutitsactivities.24ThelackofaudittrailonresponsestoSection28reportsandactiontakentopreventfuturedeathsisbothofconcernandsurprising,asthepastsummaryreportsontheoldRule43arrangements15recordedthatcoronersalmostalwaysreceivedresponsestotheirreports.Questionsariseaboutwhethertheresponseratehasdeteriorated,oralternatively,whytheresponsestoSection28reportsarenotbeingpublishedandwhetherthisisjustifiable.Thelackoftransparencyandpublicaccountabilityrunscountertotheacceptedprinciplethatjusticeshouldbeseentobedone.Togiveaspecificexample,therewasnopublishedCQCresponsetoaSection28reportonIvyAtkin’sabovedeathduetounlawfulkillingfromgrossneglect.

https://www.judiciary.gov.uk/publications/ivy-atkin/(TheCQC’sresponsetothecoronerwaspublishedsomeafter11August2017whenthefailuretopublishhadbeenpointedout).https://www.judiciary.gov.uk/publications/dorothy-clarkson/https://www.judiciary.gov.uk/publications/edwin-thompson/https://www.judiciary.gov.uk/publications/barbara-cooke/https://www.judiciary.gov.uk/publications/crittall-mr/https://www.judiciary.gov.uk/publications/beryl-farmer/https://www.judiciary.gov.uk/publications/crittall-mr/https://www.judiciary.gov.uk/publications/tommi-ray-vigrass/23MemorandumofunderstandingbetweenCQCandCoronersSocietyofEnglandandWaleshttps://minhalexander.files.wordpress.com/2016/09/mou_cqc_and_csocew_final.pdf24https://minhalexander.com/2016/11/11/coroners-warnings-terminal-inexactitude-and-cqc-opacity/https://minhalexander.com/2016/10/08/care-home-deaths-and-more-broken-cqc-promised/https://minhalexander.com/2016/09/25/letter-9-september-2016-to-david-behan-cqc-chief-executive-on-cqc-under-reporting-of-coroners-mental-health-deaths-warnings/

17

IsubsequentlyquestionedtheCQCaboutthison11thAugust2017.By14thAugust2017,CQC’sresponseappearedontheChiefCoroner’swebsite.Itwasdated21March2017.TheCQC’sresponsetothecoronershowedthatCQChadessentiallydeclinedtorectifythecentralissueaboutwhichthecoronerhadraisedaconcern.25SeriousquestionsariseaboutwhyCQC’sresponsewasnotpublishedsooner,andwhetheritwouldithavebeenpublisheditallifnoenquiryhadbeenmade.Ifresponsesarenotpublished,theycannotbechallenged.NUMBERSOFSECTION28REPORTSFromthesummaryreports15previouslypublishedbytheChiefCoroner,thiswasthedistributionoftheoldRule43reportsintime:Reportingperiod NumberofRule43reportsissued17July2008–31March2009(eightmonths)

207

1April2009–30September2009

164

1October2009–31March2010

195


175


189


210


233


186


235

Totalperiod17July2008to31March2013

1794

25Thecoronerwasconcernedaboutalegalloophole,whichcombinedwithCQC’sinterpretationofitsduties,leftsmallprovidersinchargeofscrutinisingtheirownDBScompliance.InthecaseofIvyAtkinthisloopholeallowedacarehomemanagerwithaconvictionforviolencetooperateasa‘NominatedIndividual’.ThecoroneraskedCQCtoreviewthisloophole.Initsresponsetothecoroner’sSection28report,CQCdeclinedtoseekchangestotheregulatoryarrangements.

18

Thisgivesanaveragerateof384warningreportsayear.AspreadsheetwasalsopreviouslydisclosedunderFOIandgavesimilarinformation.26Thesingle,initialsummaryreportonSection28reportsthatwaspublishedbythecurrentChiefCoronershowedthattherewere244Section28reportsissuedinthesixmonthsbetween1April2013to30September2013.27Basedoncoroners’Section28reportspublishedsofar,thenumbersofwarningreportsdonotappeartohaveincreasedgreatlyoverallsincetheswitchfromRule43reportstoSection28reports.Thisisdespitethediscretionaryreportingpowerchangingtoastatutoryduty,andthescopeforreportingincreasing.TheaverageannualrateunderthenewSection28arrangementshasbeen430reports,assumingthatmostreportsarepublished,butclarificationisneededonwhatproportionofreportshavebeenpublished.

26Forcompleteness,thiswasaspreadsheetoncoroners’Rule43reportsdisclosedviatheWhatdotheyknowwebsite:https://minhalexander.files.wordpress.com/2016/09/foi-data-what-do-they-know-all-9-summaries-of-rule-43-2010-to-2013.xlsxItgaveanaverageannualrateof405Rule43reportsayear,distributedasfollows: NumberofRule43reportsissuedby

coronersinEnglandandWales1December2009to31March2010(fourmonths)

113

Financialyear2010/11 367Financialyear2011/12 449Financialyear2012/13 420Totalperiodfrom1December2009to31March2013

1349

NBTwoRule43reportsdated2003andundatedentrieswereexcludedfromtheaboveanalysis27https://minhalexander.files.wordpress.com/2016/09/april-2013-to-september-2013-summaryreportofpfdreportsapr-sep2013-10th.pdf

19

Period NumberofallSection28reportspublished

30July2013–31March2014 3092014/15

528

2015/16

400

2016/17

439

2017/18yearto31July2017

49*

Totalperiod(30July2013to31July2017) 1725*ThislastfigureinparticularwillbeanunderestimateofSection28reportsissuedbecauseofthelaginpublication.Source:ChiefCoroner’swebsiteAUSTERITYANDDECENCYSomeSection28reportsweredisturbingintermsofwhattheyimpliedaboutourtimes.Forexample:1) Asabove,MichaelSullivankilledhimselfafterbeingfoundfittoworkbytheDWP

withoutregardtomedicalevidencefromthosetreatinghim:

“However,theultimatedecisionmaker(whoisnot,Iunderstand,medicallyqualified)didnotrequestandsodidnotseeanyreportsorlettersfromMrO’Sullivan’sgeneralpractitioner(whohadassessedhimasbeingunfitforwork),hispsychiatristorhisclinicalpsychologist.”https://www.judiciary.gov.uk/publications/michael-osullivan/

2) NathanielPhillips,ayoungman,diedofacuteasthma.Thecoronerfoundthathecould

notaffordprescriptionsandprecariouslyreliedonasthmamedicationprescribedforotherfamilymembers.TherewasnoresponsefromtheDepartmentofHealthtothecoroner’ssuggestionthatasthmamedicationsshouldbeaddedtothelistofmedicinesexemptedfromprescriptioncharges.https://www.judiciary.gov.uk/publications/nathaniel-phillips/

20

3) MalcolmBurgearetiredgardenerwithnohistoryofdebtsethimselfonfireafterNewhamCouncilpursuedhimforadebtof£800.69thatarosefromoverpaymentofhousingbenefitandcounciltaxbenefit.https://www.judiciary.gov.uk/publications/malcolm-burge/

4) Inanumberofrailwaydeaths(LewisGhessen9June2015,MichaelBovell29June

2015,LaurisKodors13September2016)coronersnotedthatRSSBrulesallowtraindriverstostopifapersononthetracksmightdamageatrain,butnotviceversa.

https://www.judiciary.gov.uk/publications/lewis-ghessen/https://www.judiciary.gov.uk/publications/michael-bovell/https://www.judiciary.gov.uk/publications/lauris-kodors/

5) TheaccidentaldeathofGarrettElseywhoshelteredinacommercialwastebinovernight.Thecoroner’ssection28reportrevealedthatnotonlydoesoursocietyneedrulestopreventinjuriestopeoplewhosleepinbins,butthatthesearenotalwaysfollowed.https://www.judiciary.gov.uk/publications/elsey-2013-0316/HealthandSafetyExecutive25:https://minhalexander.files.wordpress.com/2016/09/hse-waste25-people-in-commercial-waste-containers.pdf

6) ThedeathofSheilaBowlingwhowasknockeddownbyabusrevealedthatthebuscompanyoperatedasystemofdrivingwhichinvolvedminimalacceleration,brakingandsharpturns.Thissavesonfuel.

21

https://www.judiciary.gov.uk/publications/sheila-bowling/

CORONERS’FIRESAFETYWARNINGSBEFOREGRENFELLAftertherecentGrenfelltowerfire,itwasrevealedthattherehadbeenapreviousfatalincidentatLakanalHouse,whichwasalsoacouncilownedblockwithmajorfiresafetyfaults.AscandalaroseaboutgovernmentfailuretotakesufficientactionaftertheLakanalhouseincidentandarelatedcoroner’swarning.2829AproposconcernsthatafaultyHotpointfridgefreezermayhavetriggeredtheGrenfellblaze,itwasalsorevealedthattherehadbeenpriorconcernsraisedaboutfiresstartedbyfridgefreezers.30Generalquestionshavearisenaboutotherhousingstock,andpublicbuildingssuchashospitalsandprisons,andwhetherderegulationhasledtocostcuttingonsafetymeasuressuchassprinklers.

28https://www.theguardian.com/uk-news/2017/feb/28/southwark-council-fined-570000-over-fatal-tower-block-fire29https://www.theguardian.com/uk-news/commentisfree/2017/jun/19/grenfell-tower-lakanal-house-inquest-fire-safety30LondonFireServicestatementaboutrisksposedbyfridgefreezers3March2015http://www.london-fire.gov.uk/news/LatestNewsReleases_Fridgefreezerdelayputtinglivesatrisk.asp#.WZp2KZOGOgQ

22

ApublicinquiryintoGrenfellisnowunderway.Thisisthecoroner’sRule43documentationontheLakanalHousefire,withkeyresponses:

https://minhalexander.files.wordpress.com/2016/09/lakanal-house-ec-letter-to-dclg-pursuant-to-rule43-28march2013.pdf

https://minhalexander.files.wordpress.com/2016/09/lakanal-house-ec-letter-to-london-borough-southwark-pursuant-to-rule43-28march2013.pdfhttps://minhalexander.files.wordpress.com/2016/09/lakanal-house-ec-letter-to-london-fire-brigade-pursuant-to-rule43-28march2013.pdfhttps://minhalexander.files.wordpress.com/2016/09/lakanal-house-ec-letter-from-rt-hon-eric-pickles-mp-20may2013.pdfhttps://minhalexander.files.wordpress.com/2016/09/lakanal-house-ec-london-borough-southwark-letter-response-to-rule-43-23may2013.pdfhttps://minhalexander.files.wordpress.com/2016/09/lakanal-house-ec-london-fire-brigade-response-to-coroners-rule43-report-23may2013.pdf

Inthelastfouryears,beforetheGrenfelldeaths,therehavebeentwentycoroners’Section28reportspublishedonfirerelateddeaths.TheseSection28reportshaveincludedmatterssuchastheneedtoensurethatsprinklersandsmokealarmsareinstalledinhousingstock,especiallyforvulnerablepeoplewithreducedmobilityoratgreaterriskofcausingfires,issuesaboutemergencyresponseandcutstofireservicesandtheriskoffirepresentedbyHotpointfridgefreezersbecauseofaflammableinsulantthatcanactasafireaccelerant.Someofthecasesareasfollows:1. DeathofEmmaWaringavulnerableadult.Thecoroneradvisedthatregulationsshould

beamendedtoincludeinstallationofsprinklersespeciallyinhousingforvulnerablepeople.TherewasnopublishedresponsebytheDepartmentforCommunitiesandLocalGovernment.

23

https://www.judiciary.gov.uk/publications/emma-waring/

2. UnlawfulkillingofStephenHuntafiremanrelatedtoanincidentofarson,inwhichthe

coronermadeadetailedfindingaboutFireServiceoperationswithnationalimplications,addressedtoTheresaMayasthethenHomeSecretary.TherewasnopublishedresponsebytheHomeOffice.http://www.manchestereveningnews.co.uk/news/greater-manchester-news/stephen-hunt-inquest-jury-finds-11350611http://www.manchestereveningnews.co.uk/news/greater-manchester-news/stephen-hunt-inquest-jury-finds-11350611

3. DeathofEllenKellyinaCamdenCouncilblockofflats,inwhichthecoronerfounda

numberoffiresafetybreaches.

https://www.judiciary.gov.uk/publications/ellen-kelly/

24

4. DeathofAnthonyLappingafteradomesticfiredespiterapidrescue,becauseofalargeamountofcarbonmonoxideduetoaccelerationofthefirebytheinsulationmaterialinhisHotpointfridgefreezer.Thecoronerrecommendedon8May2014thatthemanufacturingprocessshouldbeurgentlyreviewed.Therewasnopublishedresponsefromthemanufacturer.

https://www.judiciary.gov.uk/publications/anthony-lapping/

5. DeathofSantoshMuthiahduetoafirecausedbyaBekofridgefreezer.Thecoroner

identifiedalackofsystematicinformationgatheringaboutapplianceswhichcausedfiresandmadesuggestionsforbetterlearningfromfires,includingmarkingappliancesinsuchawaythatwouldsurviveafiretoallowidentificationafterincidents.https://www.judiciary.gov.uk/publications/santosh-muthiah/Thisistheresponsefromthegovernment:https://www.judiciary.gov.uk/wp-content/uploads/2014/11/2014-0476-Response-by-Department-for-Business-Innovation-Skills.pdf

6. DeathofAmandaRichardsawheelchairboundpersoninwhichthecoronersuggestedsprinklersshouldbeinstalledinpropertieswithvulnerablepeople.https://www.judiciary.gov.uk/publications/amanda-richards/

7. DeathofJackSheldoninwhichthecoronernotedproblemswiththemanagementofmultiplecallsaboutthesameincidentandprioritisationofappliancehttps://www.judiciary.gov.uk/publications/jack-sheldon/

25

8. DeathofKennethBaileyinwhichthecoronernotedreportsfromlocalresidentsthatduetoveryparttimeopeninghoursofalocalfirestation,thefireserviceresponsewasnotasfastasitusedtobe.https://www.judiciary.gov.uk/publications/kenneth-bailey/

9. DeathofJulieAnnCammavulnerableadultwithschizophreniawhodiedbyherown

hand,settingafireintheprocess.Thecoronerexpressedconcernaboutthelackofsmokealarmsinherrentedproperty.LeedsCouncilprovidedauditinformationshowingthat18.78%ofthehousingstockstillneededsmokealarmsandcommittedto100%installation.

https://www.judiciary.gov.uk/publications/julie-ann-camm/

10. DeathofChristopherButlerrevealedaconstructionfaultthatledtoafatalelectrical

fire,butwhichwouldnotnecessarilybedetectablebyelectricaltesting

https://www.judiciary.gov.uk/publications/christopher-butler/

26

11. DeathofFrazerLiveseywhowasunabletoescapefromafireduetoexpandingdoor

andwindowsealshttps://www.judiciary.gov.uk/publications/frazer-livesey/

NHSSAFETYIwillprovidesomebroadresultsbelowandinthenextsectionIprovideamoredetailedreportonNHSambulanceservices.TheNHSfeaturedinatleast57.2%ofallSection28reportspublishedsofar(987outof1725),oftencentrally.ThisisanunderestimateastheSection28reportsdidnotalwayscontainenoughinformationtoclearlyconfirmorexcludewhetheranNHSbodywasimplicatedinthefailingsandhazardsatissue,andfurtherresearchwouldlikelyidentifyahigherproportionofNHScases.NHSfailureincasesofdeathsincustodywasespeciallyhardtoclearlyestablishfromSection28reportsbecauseofthemultiplicityoforganisationsinvolvedandpoor,opaqueCQCregistrationdataonhealthprovidersforprisonsandkindred.Therewerenopublishedresponsesto61.4%(607of987)oftheNHSSection28reports.71ofthepublishedSection28reportsrelatedtotheWelshNHSand916Section28reportsrelatedtotheEnglishNHS.AnumberofNHSbodieshavebeenthesubjectofnumerousrepeatedSection28reports.Forexample,therewere21publishedSection28reportswhichrelatedtoBrightonandSussexUniversityHospitalsNHSTrustbetweenFebruary2014andApril2017.NineteenofthesereportshadbeencopiedtotheSecretaryofState.TheCQCplacedthistrustintospecialmeasuresafterthefifteenthSection28report.Thecoroner’sfrustrationatlackofactiontoamelioraterisksispalpablefromthewarningreportsissued.Otherexamplesincluded:

- StockportNHSFoundationTrust(twentySection28reports)- TamesideHospitalNHSFoundationTrust(nineteenSection28reports)- BartsHealthNHSTrust(seventeenSection28reports)

27

- PennineAcuteNHSTrust(sixteenSection28reports)- SussexPartnershipNHSFoundationTrust(thirteenSection28reports)- NorfolkandSuffolkNHSFoundationTrust(twelveSection28reports)

ThereferencedetailsoftherelevantSection28reportsarelistedhere:

https://minhalexander.files.wordpress.com/2016/09/examples-of-nhs-trusts-which-have-been-subject-to-repeated-coroners_-section-28-reports-for-action-to-prevent-future-deaths2.pdf

SomeofCQC’sflagship‘Oustanding’trustshavealsobeensubjecttorepeatedSection28reports,somerecent,forexampleSalfordRoyalNHSFoundationTrustandWestMidlandsAmbulanceService:Coroner’sSection28reportspublishedonSalfordRoyalNHSFoundationTrustupto31July2017:1 GordonArthur,Ref.2017-0009,issued2February20172 PaulAshton,Ref.2014-0170,issued14April20143 DanielMcCallumKeane,Ref.2014-0260,issued9June144 MartinDeane,Ref.2014-0416,issued22September2014CQCratedSalfordRoyalNHSFoundationTrust‘Outstandingon27March2015“Theconceptofprovidingsafe,harmfreecarewasconsideredasaprioritybyallmembersofstaff.”5 StanleyOliver,Ref.2015-0281,issued16July20156 WendyThorne,Ref.2016-0408,issued11November20167 NatalieThornton,Ref.2017-0030,issued6February20178 KatherineDerbyshire,Ref.201,7-0199,issued16June2017

Coroner’sSection28reportspublishedonWestMidlandsAmbulanceNHSFoundationTrustupto31July2017:1 MaryWaldron,Ref.2014-0127,issued10January2014

2 CarolineCrowther,Ref.2014-0418,issued24September20143 KingsleyBurrell,Ref.2015-0472,issued20March20154 FrederickWhite,Ref.2015-0212,issued3June20155 CaraghMelling,Ref.2016–0167,issued27April2016

Inthiscase,WMASacknowledgedthatitstriagesystemdidnotdetectagonalbreathing(asignofcriticalillness)

6 JaneReason,Ref.2016-0376,issued25October2016

28

Inthiscase,WMAS’defibrillationequipmentfailedandabackupbatterywasflat.

7 RexHall,Ref.2016-0422,issued29November2016Inthiscase,thecoronerfoundthatWMASparamedicswereunabletoreadanECGinordertotellifapatienthadsufferedaheartattack)

On25January2017,CQCratedWestMidlandsAmbulanceService‘Outstanding’“Staffwerecompetentintheirrolesandprovidedwithtimelyappraisalsandlearningopportunities.”ThenumbersofpublishedSection28reportsonWelshNHSHealthBoardswereasfollows:WelshNHSHealthBoard NumberofpublishedSection28reports

upto31July2017BetsiCadwaladrUniversityHealthBoard

24reports

CwmTafUniversityHealthBoard 13reportsAbertaweBroMorgannwgUniversityHealthBoard

10reports

CardiffandValeUniversityHealthBoard 9reports

HywelDdaUniversityHealthBoard 6reportsAneurinBevanUniversityHealthBoard 6reportsPowysTeachingHealthBoard 1reportThesearetherelevantcasereferencesforWelshhealthboards:

https://minhalexander.files.wordpress.com/2016/09/section-28-reports-relating-to-welsh-nhs-health-boards-published-by-the-chief-coroner-up-to-31-july-2017.pdf

Ishouldstressagainthatthesefiguresarebasedononlyonpublishedreports,andthatclarificationisneededontheactualnumberofreportsissued.Also,organisationsmaysometimeshavelowernumbernumbersofcoroners’warningsdespitesafetyconcerns.Forexample,SouthernHealthNHSFoundationTrustattractedonlyahandfulofcoroners’warningreportsintheperiodinwhichhundredsofdeathswerenotproperlyreviewed.31

31TheMazarsdeathsreviewofSouthernHealthNHSFoundationTrustreportedthattherewere375inquestsontrustpatientsduringtheperiodcoveredbythereview(April2011toMarch2015)–page174:

29

Thedatawillneedfurtherexaminationandcrosscheckingwithothersources.Mybroadimpressionofitsofaristhatitunsurprisinglyshowsstrainontheservice,withinstancesofdisorganisationanderror,aswellasnumberofcoroners’remarksaboutlackofresourcesandunderstaffing.Forexample,inthedeathofapatientfrominfectionaftersurgery,thecoronernotedthatstaffhadreportedthattheywereoverwhelmedduetounderstaffingandthatthiswasnotunusual:“Thefirstmatterofconcernwasthatthreewitnesseswhogaveevidence,twoSeniorNursesandoneDoctor,toldmethatonthenightthatSaradiedtherewereinsufficientmembersofstaffavailabletodealwiththecaseloadofpatientsandthiswasnotunusual.Theyfeltoverwhelmedandyetunabletoescalatethecare”https://www.judiciary.gov.uk/publications/sari-keen/ThereweresignsoffailuretolearnbytheNHS,andsometimesthe‘matterofconcern’wasinfactfailuretoconductseriousincidentinvestigationsafterdeathseitherproperlyoratall,ortoactupontherecommendationsfromdeathsinvestigations.IwasstruckathowmanyoftheSection28reportsrelatedtofailurestodeliverbasicofcaretoolderpeople–skincare,fallsprevention,supportwitheating,andsafemedicinesmanagement(especiallyofanticoagulants).Coronerssometimesdrewexplicitlinksbetweensuchcarefailingsandunderstaffing.Insomecases,fallsandotherharmoccurredafteraneedforonetoonecarewasidentifiedbutnotdelivered.Evenwherecoronersmadenospecificfindingsaboutstaffing,thenatureoftheunmetneeditselfraisedquestionsofsafestaffing.

https://www.england.nhs.uk/south/wp-content/uploads/sites/6/2015/12/mazars-rep.pdfAccordingtoChiefCoroner’sdata,duringthisperiodthetrustwassubjecttooneRule43reportandoneSection28report.

30

ToputahumanfaceontheNHSSection28reports,hereareafewstrikingcases:

ErrolManndiedofpulmonaryembolismafterfailuretoameliorateknownrisks.ITUstaffinglevelsreportedlycontributedtohisdeath.Awitnessreportedthattherewerepersistentmedicalstaffrotagaps,akeyissueinthebitterdisputebetweentheSecretaryofStateandthejuniordoctors.TherewasnopublishedresponsefromanypartysenttheSection28reportforactiontopreventfuturedeaths.https://www.judiciary.gov.uk/publications/errol-mann/

DrJohnDaviesdiedalonelydeathbyhisownhandinahotelroom,withafindingbythecoronerabouttheGMC’sbehaviourtowardsdoctorswhowerethesubjectofcomplaints.TherewasnopublishedresponsebytheGMCtotheSection28report.https://www.judiciary.gov.uk/publications/john-davies/AlvaJulliendiedofpneumoniadueto‘recumbency’imposeduponherbydelayeddischargefromhospitalfornogoodreasonanddespitethefactthatherfamilywouldhavebeenwillingtocareforher.Shewasmadenilbymouthwithoutsufficientevidencethatthisiswasappropriate,andplacedonthenotoriousLiverpoolcarepathway.TherewasnopublishedresponsebyStockportNHSFoundationTrusttotheSection28report.https://www.judiciary.gov.uk/publications/jullien-2013-0232/MohammedChaudhurysufferedmultipleinjuriesafteratrafficcollisionanddiedofsepticpressuresoresof‘unusualinextentandseverity’whichdevelopedatKingsCollegeHospitalNHSFoundationTrust.TherewasnopublishedresponsefromthetrustorfromMikeRichards,formerCQCChiefInspectortotheSection28report.https://www.judiciary.gov.uk/publications/mohammed-chaudhury/CarolGibsondiedofafatalreactiontoadrugwhichshehadbeenprescribedforafourthandfinaltimeinerrorbyherGPpractice,allafterithadbeenflaggedbyhospitalsservicesthatshehadsufferedanearlier,seriousadversereactiontothisdrug.TherewasnopublishedresponsebyherGPsurgeryorbyNHSEnglandtotheSection28report.https://www.judiciary.gov.uk/publications/carol-ann-gibson/

31

PROPORTIONOFCORONERS’WARNINGSABOUTTHENHSNHSdeathshavealwaysfeaturedprominentlyincoroners’warnings,buttherehasbeenanincreaseintheproportionofNHScasesovertime.TheincreasestartedduringtheyearswhenRule43arrangementswereinplace:Reportingperiod NumberofallRule43

reportsissuedNumberofRule43reportsissuedaboutNHShospitalsandtrusts

17July2008–31March2009(eightmonths)

207 78(37.6%)


164 65(39.6%)


195 74(37.9%)


175 72(41.1%)


189 86(45.5%)


210 106(50.4%)


233 120(51.55%)


186 102(54.8%)


235 103(43.8%)

Totalperiod17July2008to31March2013(**months)

1794 806(44.9%)

Source:Bi-annualChiefCoronersummariesonRule43reportsCautionisneededindrawingconclusionsfromsubsequentpublishedSection28reportsastheydonotrepresentacompletedataset.Reportsarealmostcertainlymissing,especiallyforthelastyearorso,becauseofthelageffectinpublication.Rule43reportsandSection28reportsarealsonotfullycomparable.

32

Butforcompleteness,thishasbeenthedistributionovertimeofpublishedcoroners’Section28reportsontheNHS(includingprimarycare).Period NumberofallSection28reports

publishedNumberofSection28reports

publishedaboutallNHSservicesincludingprimarycare

20July2013–31March2014

309 167(54%ofallreports)

2014/15

528 309(58.5%ofallreports)

2015/16


2016/17


2017/18yearto31July2017


Totalperiod(20July2013to31July2017)


CORONERS’WARNINGSABOUTAMBULANCESERVICESANDRELATEDMATTERSTheeffectivenessofambulanceservicesmatterstoall.Ambulanceperformanceisamatterofpoliticalsensitivityasarethecontroversialschemesfordivertingpatientstolessacuteformsofcare,whichsomehavecriticisedasameansofsavingmoneyanddowngradingservices.32Thereare10EnglishNHSambulancetrustsandoneWelshambulancetrust.Theyoperateundergreatpressure.EnglishnationalNHSstaffsurveyreturnsforambulancetrustsshowthehighestlevelsofbullyingoutofalltypesofNHStrusts(averageof28%in2016).Ambulancetrustsalsoreturnverylowscoresoncommunicationbetweenstaffandsenior

32NHStorevamp111helplineaftersustainedcriticismofservice,DenisCampbellGuardian8March2017https://www.theguardian.com/society/2017/mar/08/nhs-to-revamp-111-helpline-after-sustained-criticism-of-serviceNationalreviewofschemestodivertpatientsfromA&Eamidsafetyfears,LauraDonnellyTelegraph23July2017http://www.telegraph.co.uk/news/2017/07/23/exclusive-national-review-schemes-divert-patients-ae-amid-safety/

33

management,withanEnglishnationalaverageofjust19%ambulancetruststaffreportinggoodcommunicationwithseniormanagersin2016.Key2016staffsurveyresultsonEnglishambulancetrusts:AmbulanceService Staff-staffbullying

intheprevious12months

Staffreportinggoodcommunicationwithseniormanagement

OverallCQCrating

EastMidlands 28% 17% Requiresimprovement

EastofEngland 29% 19% Requiresimprovement

London 32% 22% Requiresimprovement

NorthEast 25% 18% GoodNorthWest 28% 20% Requires

improvementSouthCentral 23% 22% GoodSouthEastCoast 40% 12% InadequateSouthWestern 21% 28% Requires

improvementWestMidlands 33% 19% OutstandingYorkshire 29% 15% GoodSource:NationalNHSstaffsurveyNB.TheNationalNHSstaffsurveyresultsstatedthatthebeststaff-staffbullyingscoreforanambulancetrustin2016was14%,butIfoundnotrustwithsuchascore.Ihaveaskedtheproviderorganisationwhichoperatesthestaffsurveyaboutthis.StaffsurveydatafortheWelshAmbulanceservicein2016revealedthat21%ofstaffreportedbullyingbyotherstaffand21%ofstaffreportingthatcommunicationwithseniormanagerswaseffective.

http://www.ambulance.wales.nhs.uk/assets/documents/5da36e00-1e47-4285-854c-0fa55e788f50636175031416660627.pdf

Whistleblowingbyambulancestafftothemediahasnowbecomearegularoccurrence.33

33Pressreportsofwhistleblowingaboutambulancesandrelatedservices:http://www.edp24.co.uk/news/health/second-whistleblower-says-under-fire-ambulance-trust-is-also-using-volunteer-community-first-responders-to-hit-targets-1-5107179http://www.edp24.co.uk/news/health/second-whistleblower-says-under-fire-ambulance-trust-is-also-using-volunteer-community-first-responders-to-hit-targets-1-5107179

34

Curiouslythough,therearenopublishedCQC‘intelligentmonitoring’reportsatallonambulancetrusts.ItwasthereforenotpossibletochecktheextenttowhichCQChasreceivedwhistleblowingalertsaboutambulanceservices.33

https://www.hsj.co.uk/east-of-england-ambulance-service-nhs-trust/exclusive-whistleblower-warns-trust-is-worst-its-ever-been-as-staff-shortage-revealed/7020389.article#.WZgIBxoBC3Q.twitterhttp://www.telegraph.co.uk/news/2017/02/13/bullying-desperate-999-call-handlers-led-suicide-attempts-scandal/http://www.bristolpost.co.uk/news/bristol-news/whistleblower-nhs-bristol-ambulance-paramedics-163044http://www.bbc.co.uk/news/uk-england-38694213http://www.yorkpress.co.uk/newS/11682028.Row_after_launch_of_ambulance_service_whistleblower_website/?commentSort=scorehttp://www.mirror.co.uk/news/uk-news/ambulance-service-crisis-warns-paramedic-6961702http://www.plymouthherald.co.uk/probe-launched-whistleblower-s-claims-health/story-29308468-detail/story.htmlhttp://www.bbc.co.uk/news/health-38535946https://www.hsj.co.uk/hsj-local/providers/south-western-ambulance-service-nhs-foundation-trust/exclusive-regulator-to-probe-whistleblower-ambulance-trust/7004930.articlehttp://archive.camdennewjournal.com/news/2011/oct/whistleblower-says-ae-ambulance-crews-go-out-without-paramedicshttps://planetradio.co.uk/mfr/local/news/watch-safety-watchdog-looking-north-ambulances/https://www.spectator.co.uk/2014/08/londons-999-emergency/33CQC‘intelligentmonitoring’reportsareoflimiteduseinprovidinginformationonwhistleblowingeventsastheyonlysaywhethertherehavebeenalertsreceivedduringagivenreportingperiod,withoutindicatinghowmanyreportshavebeenreceived.

35

TheRule43andSection28datashowsthattherehasbeenanincreaseincoroner’swarningsaboutambulanceservices,andinparticularthenumberofwarningsaboutambulancedelays.UndertheoldRule43arrangementstherewereatotalof48coroners’warningreportsaboutambulancetrustsbetweenJuly2008andMarch2013:Reportingperiod NumberofRule43reportsissued

AboutNHSambulancetrusts17July2008–31March2009(eightmonths)

3


4


4


7


7


7


4


5


7

TOTALforperiod17July2008to30September2013(62months)

48

Source:ChiefCoroner’sbi-annualsummariesofreportsandresponsesunderRule43ofCoronersRulesThesearetherelevantcasereferencedetails,summarisedissuesofconcernsandambulanceservicesinvolved:

https://minhalexander.files.wordpress.com/2016/09/rule-43-reports-on-nhs-ambulance-services-pub1.xlsx

DuringtheperiodJuly2008toMarch2013,therewerethreeRule43reportsthatexplicitlyrelatedtoambulanceresponsetimesorambulanceservicecapacity(LondonAmbulanceService,WelshAmbulanceServiceandSouthCentralAmbulanceService)

36

Sincethen,thereseemstohavebeenanincreaseincoroners’concernsasIfoundatotalof84coroners’Section28reportsonambulanceservices,andtwoSection28reportsonrelatedcallhandling,thathavebeenpublishedupto31July2017.FINANCIALYEAR NUMBEROFPUBLISHEDCORONERS’SECTION

28REPORTSRELATINGTOAMBULANCESERVICESANDRELATEDCALLHANDLING

2013/14(30July30to31March2014) 122014/15 192015/16 222016/17 272017/18upto31July2017 6TOTAL 86AlmostalltheSection28reportsonambulanceservicesrelatedtoNHSservices,butthreeprivateambulanceservicesfeatured.TheLondon,NorthWest,EastMidlands,WestMidlandsandWelshAmbulanceServicesaccountedforthemostpublishedcoroners’warningsintheNHS:NHSambulancetrust Numberofcoroners’Section28reports

publishedupto31July2017LondonAmbulanceService 18NorthWestAmbulanceService 13EastMidlandsAmbulanceService 9WestMidlandsAmbulanceService 7WelshAmbulanceService 7EastofEnglandAmbulanceService 6NorthEastAmbulanceService 4SouthWesternAmbulanceService 6YorkshireAmbulanceService 6SouthEastCoastAmbulanceService 3SouthCentralAmbulanceService 3Importantly,48ofthe86(55.8%)publishedSection28reportsonallambulanceservicesnoteddelaysinambulanceresponseanddiversiontolessacuteserviceswhichhadeithercontributedtodeathsorcouldcontributetodeathsinfuture.

37

Thereappearedtobeanincreasingtrendinreportsaboutdelays,especiallycomparedtotherelativelylownumberofwarningsaboutdelaysundertheoldRule43arrangements.FINANCIALYEAR NUMBEROFPUBLISHEDCORONERS’SECTION

28REPORTSRELATINGTOAMBULANCESERVICEDELAY&RELATEDISSUESOFCALLHANDLINGANDDIVERSIONTOLESSACUTESERVICES

2013/14(30July30to31March2014) 62014/15 82015/16 132016/17 162017/18upto31July2017 5TOTAL 48EvenallowingforthefactthatSection28andRule43reportsarenotwhollycomparable,theincreasefromthreeRule43reportsonambulancedelaysto47Section28reportsonambulancedelayssuggeststhatthereisarealproblem.EightofthepublishedSection28reportsfeaturingcasesofambulancedelayhadbeensenttotheDepartmentofHealth.35ThisisthesupportingdataonalltheambulanceandrelatedSection28reportsfromthelastfouryears:

https://minhalexander.files.wordpress.com/2016/09/section-28-reports-on-ambulance-services-published-up-to-31-july-2017-pub.xlsx

ApartfromtheSouthCentralAmbulanceService,allNHSambulancetrustsreceivedoneormoreSection28reportsrelatingtodelayedambulanceresponse

35TheeightambulanceSection28reportsthatweresenttotheDepartmentofHealth:YusufAbdismad:https://www.judiciary.gov.uk/publications/yusuf-abdismad/LiamColemanhttps://www.judiciary.gov.uk/publications/liam-coleman/RobertHogghttps://www.judiciary.gov.uk/publications/robert-hogg/PaulMurrayhttps://www.judiciary.gov.uk/publications/paul-murray/BarbaraPattersonhttps://www.judiciary.gov.uk/publications/barbara-patterson/KeithRustonhttps://www.judiciary.gov.uk/publications/keith-ruston/PeterScotthttps://www.judiciary.gov.uk/publications/peter-scott/JamesSuttonhttps://www.judiciary.gov.uk/publications/james-sutton/

38

Moreover,someofthecoroners’remarksindicatedthattherehadbeenpreviousincidentsofdelayandrelatedsystemicissues.Coronerspointedoutthatambulancedelayswereduetocapacityandcloselyrelatedtootherseverepressuresinthesystem,whichcausedelaysinhospitalhandoverandambulancequeuingatA&Edepartments.CompoundingproblemsofservicecapacityandhandoverdelaysatA&E,therewerealsoissuesabouttheeffectivenessandsafetyofcallhandlinganddiversionservices.Insomedeaths,referralstoambulanceserviceshadbeenassignedlowerprioritythanwasappropriate.Aquestionarisesofwhetherthisispartlyaconsequenceofasystemthatissooverwhelmedthatitisunderstandablyandforeseeablybecomingde-sensitisedtorisk.Someexamplesfollow.

Afteradeathinwhichittookoneandhalfhoursforanambulancetoattend,thecoronerforExeterandGreaterDevonnotedon21June2017:

https://www.judiciary.gov.uk/publications/colin-james/TheBrighton&Hovecoronernotedon5April2017:

39

https://www.judiciary.gov.uk/publications/ronald-bennett/

Onthe21June2017theExeterandGreaterDevoncoronernoted:

https://www.judiciary.gov.uk/publications/colin-james/Afterthedeathofapatientwhohadbeenwaitinginanambulancequeuefor7hours,thecoronerforNorthWales(EastandCentral)notedon14March2017:

https://www.judiciary.gov.uk/publications/rebecca-evans/Afteraneonataldeath,theNottinghamshirecoronernotedon11May2016:

40

https://www.judiciary.gov.uk/publications/mia-gibson/

On17November2016thecoronerforHertfordshirenoted:

https://www.judiciary.gov.uk/publications/brian-mills/

On25May2016thecoronerforNottinghamshirenoted:

41

https://www.judiciary.gov.uk/publications/peter-scott/TheSouthWalesCentralcoronernotedon20April2016:

https://www.judiciary.gov.uk/publications/ronald-hamer/Afterthedeathofa28yearoldwomanfromhaemorrhageduetorupturedectopicpregnancy,thecoronerforInnerLondonNorthnoted:

42

https://www.judiciary.gov.uk/publications/sabrina-stevenson/On23March2016thecoronerforTeesidenoted:

43

https://www.judiciary.gov.uk/publications/mandeep-singh/On12October2015theNorthamptonshirecoronernoted:

https://www.judiciary.gov.uk/publications/mrs-withers/On22September2015thecoronerforCentralLincolnshirenoted:

44

https://www.judiciary.gov.uk/publications/stuart-knight/On21May2015thecoronerforNorthNorthumberlandnoted:

https://www.judiciary.gov.uk/publications/barbara-patterson/

On13May2015theNorthLondoncoronernoted:

45

https://www.judiciary.gov.uk/publications/paul-murray/

On6August2015theBuckinghamshirecoronernoted:

https://www.judiciary.gov.uk/publications/robert-hogg/

Afterthedeathofa15yearoldgirlthecoronerforInnerLondonWestnotedon19December2014:

46

https://www.judiciary.gov.uk/publications/samia-shara/

On12September2014thecoronerforEastandCentralNorthWalesnoted:

https://www.judiciary.gov.uk/publications/clive-turner/On9January2014theBedfordshireandLutoncoronernoted:

47

https://www.judiciary.gov.uk/publications/albert-james-hand/On30October2013thecoronerforPowys,BridgendandGlamorganValleysnoted:

https://www.judiciary.gov.uk/publications/johns-2013-0279/Alsoofconcern,therewerenopublishedresponsesto50oftheSection28reportsonambulanceservicesandkindred.Specifically,therewerenopublishedresponsesto26ofthe48Sectionreportsaboutambulancedelays.OfthirteenSection28reportsaboutambulanceservices,addressedtotheDepartmentofHealthforactiontopreventfuturedeaths,therewasnopublishedresponseinelevencases.

48

Ofthepublishedresponsesbythegovernmentandcentralbodiesaboutambulancedeaths,therewererepeatedpromisestoreviewandmentionsofworkinprogress,includinganNHSEnglandreviewledbyBruceKeoghNHSEnglandMedicalDirector.However,thecontinuingstreamofcoroner’swarningssuggeststhatseriousrisktothepublicisnotbeingamelioratedquicklyenough.CONCLUSIONThepublishedSection28reportdataforEnglandandWales,itscompletenessandpresentationraiseissuesofgovernmenttransparency,learningfromdeathsandwhetherthegovernmentisdoingenoughtoprotectthepublic.TheincompletedataonresponsestoCoroners’warningsandtheapparentlackofaclearprocessfordealingwithunsatisfactoryresponsesraisequestionsaboutthepurposeandeffectivenessoftheSection28reportingsystem.Theauditcycleneedstobemoreclearlyandproactivelyclosed,withproperaccountabilitytothepublic.Failuretotakeactioninresponsetoavoidabledeathsorunacceptableriskstothepublicshouldnotbeexposedbythenextsimilardeath,asseemstobeimpliedbysomeoftheSection28reports,butbyactivetrackingbytheState.Thehundredsofcoroners’warningsabouttheNHSandnotwithstandingthecaveatsaboutthedata,anapparentescalationinwarningsaboutNHSemergencyservicesemphasisetheneedtoforthegovernmenttodemonstratethatitistakingeffectiveaction.Thedataonrepeatedcoroners’warningsaboutambulancedeathsandseriousrisktopublicsafetycallsintoquestionthevalidityofCQC’sregulatoryperformanceandfindings.Inparticular,CQC’srecentratingofWestMidlandsAmbulanceServiceas‘Outstanding’36ishardtoreconcilewiththerealityontheground.

36http://www.cqc.org.uk/provider/RYA

49

CQChaspreviouslybeencriticisedonanumberofoccasionsfornotactinguponintelligencefromcoroners.AfteronesuchoccasionCQCissuedatypicalpressreleaseinSeptember2015promisingtolearnlessons–seeappendixbelow,butquestionsariseaboutwhetherthelessonshavebeeneffectivelylearned.IhavewrittentotheChiefCoronertoseekclarificationaboutanumberofmattersincludinghowmanySection28reportsandresponseshavebeenpublished,theprocessesgoverningpublicationandnonresponsetoSection28reports.IhavealsoaskedthattheSection28dataonhiswebsiteismademoreaccessibletothepublic.TheDepartmentofHealthandothercentralNHSbodieswillalsobeaskedtoexplainmoreabouttheirhandlingofSection28reports.DrMinhAlexander24August2017APPENDIX-PRESSCRITICISMOFCQCFAILURETOACTUPONCORONERS’WARNINGSANDCQCRESPONSESEPTEMBER2015

Elderlypeopleputatriskaswatchdogfailstoactonwarningsof‘fatallynegligent’carehomes,MelanieNewmanandOliverWright,Independent,2September2015:

http://www.independent.co.uk/life-style/health-and-families/health-news/elderly-people-put-at-risk-as-watchdog-fails-to-act-on-warnings-of-fatally-negligent-care-homes-10483573.html

CQCresponsetostoryinTheIndependent

Published:3September2015Categories:Public

AstoryhasbeenpublishedinTheIndependenttoday(Thursday3September)focussingonCQC’sresponsetoRegulation28reports,whichareissuedbytheCoronerandaimedatpreventingfuturedeaths.

Thestoryfocussesonanumbercases(between2013and2015)wheresomeonedied-eitherinacarehomeorfollowingcareortreatmentathome-wheretheCoronerconcludedthatfurtheractionneededtobetakentopreventafuturedeathinsimilarcircumstancesfromoccurring.

50

OurChiefExecutive,DavidBehan,gaveaninterviewtoTheIndependenttoexplainhowCQChasimprovedtheprocesseswehavetoinplacetoensurethatwerespondtoandlearnfromtheissueshighlightedbytheseRegulation28reports.

CQC’sChiefExecutive,DavidBehan,said:.

“WhensomeonedieswhilebeingcaredforinahealthorsocialcaresettingandtheCoronerconcludesthatactionisneededtopreventfuturedeathsfromoccurring,aRegulation28reportisissued.Inmostcases,theproviderwillbethenamedrespondent,meaningthattheyhaveresponsibilityforpreventingafuturedeathinsimilarcircumstances.

“Insomecases,however,CQCisthenamedrespondent,meaningthattheCoronerhasconcludedthattheregulatoralsohasaroletoplayinensuringthatpeopleareprotectedinthefuture.

“InthosecaseswhereCQCisidentifiedasthenamedrespondent,itisabsolutelyrightthatweshouldexpectCQCtousethisinformationtoinformourregulatoryactivities.ThisincludeshowwerespondtolevelsofriskaswellasensuringprovidersactontherecommendationsofCoroner’sReports.

“Lastyear,Iinitiatedareviewofourprocessesandprocedures,asIhadrecognisedthatwewerenotalwaysreceivingtheseReports.Insomecaseswherewedid,itwasalsoclearwewerenotalwaysdealingwiththeseeffectivelyenough.

“Wehavemadeanumberofchangestostrengthenandtightenourwaysofworking,including:

• EstablishingasinglepointofcontactforCoroners’reportstoensureanyconcernsraisedareeffectivelylogged,analysed,managedandreviewed.

• BetterandearlierengagementwithCoronersaroundthetimeofaperson’sdeath.• AproposedanddraftedMemorandumofUnderstandingwiththeCoroners’Society

tostrengthenourworkingrelationshipsandensurewereceiveallCoroners’reportsinhealthandsocialcareinquestsinordertohelpreduceriskmoreeffectivelyandpromptly.

“We’vemadeprogress,butI’mfarfrombeingcomplacent.Weknowthereismoreworktodo.Improvementisacontinualcommitmentandwearemakingsureweareproperlyembeddingournewprocess,furtherdevelopingourrelationshipwiththeCoroners’Societyandbeingreallyclearaboutwhatweexpectourstafftodowhentheyreceivethesetypesofreports.

“Butthisisn’tjustaboutprocesses–it’saboutpeople’slives.Forthatreason,weneedtokeepworkinghardtoensurethatwegetitrighteverytime.”

Lastupdated:

51

29May2017

https://www.cqc.org.uk/news/stories/cqc-response-story-independent

Documents

Four years of published coroners_ Section 28 reports to ... · prevent future deaths in England and Wales ... Database of 4 years of coroners’ Section 28 warning reports, published