Source · Prevention of Future Deaths
Roger Neaves
Ref: 2019-0130-wp26624
Date: 18 Apr 2019
Coroner: Ian Arrow
Area: Plymouth Torbay and South Devon
Responses identified: 0 / 1
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Confirmation is needed that the recommendations from the Hospital Trust's Root Cause Analysis following the patient's death have been fully implemented.
Date
18 Apr 2019
56-day deadline
13 Jun 2019
Responses identified
0 of 1
Coroner's concerns
Confirmation is needed that the recommendations from the Hospital Trust's Root Cause Analysis following the patient's death have been fully implemented.
View full coroner's concerns
The Coroner received evidence from the author of a Root Cause Analysis conducted by the Hospital Trust following Mr Neaves's death: That Root Cause Analysis made various recommendations which required action by the Hospital Trust. The Coroner is concerned to receive confirmation that the recommendations have been fulfilled, day his his The
Report sections
Investigation and inquest
At an Inquest hearing at Coroner's Court; Derriford Park; Plymouth on the 17th of April 2019 heard before Ian Michael ARROW, Senior Coroner, the following findings and determinations were made: Name of the deceased: Roger Albert NEAVES Medical Cause of Death: Ia Sepsis 1b Pneumonia Ic Fractured Neck of Femur (left) Parkinson Disease The Coroner recorded conclusion as Accident
Circumstances of the death
The deceased fell in his bedroom on 16 October 2018. He fractured left femur. He was conveyed to hospital: He deteriorated and died on 18 October 2018.
Action should be taken
In my opinion action should be taken to prevent future deaths and believe you as Medical Director have the power to take such action to ensure the recommendations are fulfilled. YouR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 13 June 2019. !, 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:
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Report details
- Reference
- 2019-0130-wp26624
- Date of report
- 18 April 2019
- Coroner
- Ian Arrow
- Coroner area
- Plymouth Torbay and South Devon
Responses identified
Responses identified
0 of 1
1 response not yet linked
Organisations named in PFD reports are normally expected to respond within 56 days. Deadline: 13 Jun 2019.
Sent to
- Derriford Hospital Trust