Source · Prevention of Future Deaths
Daniel Strickland
Ref: 2015-0505
Date: 20 Feb 2015
Coroner: Sarah Whitby
Area: Southampton and the New Forest
Responses identified: 0 / 1
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Deficient information management included a lack of written handovers, inaccurate logs, an inaccessible daily log, and no clear method for sharing critical medical information with external parties.
Date
20 Feb 2015
56-day deadline
17 Apr 2015 est.
Responses identified
0 of 1
Coroner's concerns
Deficient information management included a lack of written handovers, inaccurate logs, an inaccessible daily log, and no clear method for sharing critical medical information with external parties.
View full coroner's concerns
_ _ (1)Lack of a written handover between evening and night supervisors at St Edwards School (2)Movement that was not completed accurately or with enough detail
3)Daily log that was not easily accessible and was misleading
4)No clear method of centrally and accurately_recording significant medical events to May day day: log facilitate passage of information to non ~school persons_
3)Daily log that was not easily accessible and was misleading
4)No clear method of centrally and accurately_recording significant medical events to May day day: log facilitate passage of information to non ~school persons_
Report sections
Investigation and inquest
On 28th 2014 commenced an investigation into the death of Daniel Stickland aged
17. The investigation concluded at the end of the inquest on 13th February 2015. The conclusion of the inquest was death from natural causes; Medical cause of death:
1.a Sudden Cardiac Death with Morphologically Normal Heart
2.Epilepsy
17. The investigation concluded at the end of the inquest on 13th February 2015. The conclusion of the inquest was death from natural causes; Medical cause of death:
1.a Sudden Cardiac Death with Morphologically Normal Heart
2.Epilepsy
Circumstances of the death
On the 14th May 2014 the deceased was found collapsed having fallen from bed at his residential school St Edwards_ He had been under investigation for seizures but no diagnosis had been made_ Earlier that he had had two seizures now recognised as indicating a form of epilepsy and after the second emergency services were called but did not take him to hospital. On the information presented and in the way presented from non -medically trained school staff and from their own observations of Daniel the emergency personnel felt there was no need to do so. Daniel was taken to Southampton General Hospital where he was pronounced dead the following
Action should be taken
In my opinion action should be taken to improve record keeping and streamline the recording of significant events, to ensure staff and outside bodies are accurately briefed in emergencies. Further action should be taken to direct responsibility for all medical matters in a proper chain of command These actions should be taken s0 as to prevent future deaths and believe your organisation has the power to take such action.
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Report details
- Reference
- 2015-0505
- Date of report
- 20 February 2015
- Coroner
- Sarah Whitby
- Coroner area
- Southampton and the New Forest
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: 17 Apr 2015 (estimated).
Sent to
- St Edward’s School