Source · Prevention of Future Deaths

Hayley Gascoigne

Date: 1 Oct 2018 Coroner: Paul Marks Area: East Riding and Kingston-upon-Hull 1 response identified · 1 indexed addressee View PDF

AI-generated concerns summaryThe coroner noted the absence of a defibrillator at Hull Combined Court Centre, despite expert evidence on its importance for patient survival in cases of shockable cardiac dysrhythmia.

Date 1 Oct 2018

56-day deadline 26 Nov 2018 est. estimated from the report date

Responses identified 1 of 1

Other related deaths

Coroner's concerns

AI summary

The coroner noted the absence of a defibrillator at Hull Combined Court Centre, despite expert evidence on its importance for patient survival in cases of shockable cardiac dysrhythmia.

View full coroner's concerns

Expert evidence was heard that in the presence of "shockable cardiac dysrhythmia" such as ventricular fibrillation, the administration of a shock from defibrillator can restore the normal cardiac rhythm and that the longer the application of such shock is delayed, the greater the likelihood is that the patient will succumb to this untoward cardiac event. number of public buildings are provided with defibrillation apparatus_ but our preliminary enquiries indicate that the Hull Combined Court Centre did not have one at material times_ The Independent Accident and Emergency Expert believes that all buildings should be equipped with such an apparatus given that the quicker a shock is applied the greater the probability is that a patient will survive would ask you to reply to me within 56 as to whether the Court Complex now has a defibrillator or whether there are plans in place for such an apparatus to be secured If there are no plans then | would require you to tell me why this is not being considered given the obvious benefit of having such equipment available in public places_ am copying this report to HM Courts and Tribunals Services to bring the problem of lack of defibrillators in public buildings such as Courts to their attention_ In the circumstances it is statutory duty to report to you: days my

Responses

1 respondent

HG

Letter dated 26 Oct 2018 PDF

AI-classified response stance Action Taken

AI-generated response summary

• A defibrillator has been installed at Hull Combined Court Centre. • Staff at the centre have been briefed regarding the defibrillator.

View full response

Dear Professor Paul Marks

Re: Regulation 28 Report to Prevent Future Deaths in respect of the Inquest touching upon the death of Hayley Emma Gascoigne (deceased)

Thank you for the report dated 1st October 2018 in respect of the above, made under Paragraph 7, Schedule 5 of the Coroner's and Justice Act and Regulations 28 and 29 of the Coroner's (Investigation) Regulations 2013.

In respect of actions to be taken. I can confirm that Hull Combined Court Centre now has a defibrillator located on site, and staff have been briefed accordingly.

I do hope this answer's your enquiry, should you require anything else from me, please do not hesitate to get in touch.

Report sections

Investigation and inquest

On 01/02/2017 commenced an investigation into the death of Hayley Emma GASCOIGNE: The investigation concluded at the end of the inquest 28th June 2018. The conclusion of the inquest was Hayley Emma GASCOIGNE died on the 26th January 2017 at Hull Royal Infirmary, Hull She died from the natural disease processes listed under the medical cause of death: Ia) Acute left ventricular failure 1b) Hypertensive heart disease

Circumstances of the death

The deceased, Hayley GASCOIGNE, had been in attendance at Hull Crown Court with her parents and sister , regarding Family Case regarding access to see her child_ The matter was to be heard over three the day of her death being the second. Hayley's parents and sister have described Hayley as being emotional and upset having had many months of stress and upset following intervention by Social Services and other agencies regarding her children, and as a result of domestic violence from her partner The Court had adjourned for a lunch break at 12.45hrs informing Hayley to be back to continue the hearing at 14.00hrs She left with her family and attended the local Weatherspoons Pub for lunch, where she consumed an egg and bacon sandwich She left and arrived back at the court with her family for the continuation of the hearing at 14.00hrs_ Whilst in court Hayley's father heard her say to him that she had 'tremors in her heart' . The Court case concluded after about half an hour. Hayley was visibly upset with the outcome which was not to her advantage. She left the Court room with her family and walked directly to the female toilets alone. Hayley' s mother suggested to Hayley's sister that she should go and check on her; which she did not do, instead, leaving the deceased to have space and time alone. Her sister stated that her Hayley had been gone for about three minutes, but no longer than five minutes before she_returned, Hayley sat on a chair next to her gQV. days, sister on the upper concourse area of the Court building: The deceased was heard by her sister to say to her that she felt 'dizzy and sick'. Her sister then describes her Hayley as becoming yellow in skin colour and her mouth dropping to one side before her eyes rolled back in her head, her head falling backwards and her body becoming stretched out and rigid. Her eyes and mouth continued to contort until it was realised something was wrong Court staff intervened and provided medical assistance whilst an ambulance was called, which arrived at the court at 14.28hrs_ Haley was conveyed to Hull Royal Infirmary where at 15.38hrs life was pronounced extinct.

Action should be taken

In my opinion action should be taken to prevent future deaths and believe you have the power to take such action.

Copies sent to

uponHull

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Report details

Date of report: 1 October 2018
Coroner: Paul Marks
Coroner area: East Riding and Kingston-upon-Hull

Responses identified

Responses identified 1 of 1

All listed responses identified

Organisations named in PFD reports are normally expected to respond within 56 days. Deadline: 26 Nov 2018 (estimated from the report date).

Sent to

HM Courts and Tribunals Services

The Hull Combined Court Centre, Lowgate, Kingston upon Hull

Source links

Judiciary.uk page → Report PDF →

Data: judiciary.uk.

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