REGULATION 28: REPORT TO PREVENT FUTURE DEATHS
REGULATION 28 REPORT TO PREVENT FUTURE DEATHS
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THIS REPORT IS BEING SENT TO:
1) The Lakes Care Centre
2) Secretary of State for Health and Social Care
3) Care Quality Commission
CORONER
I am Alison Mutch, Senior Coroner, for the coroner area of South Manchester
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CORONER’S LEGAL POWERS
I 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
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INVESTIGATION and INQUEST
On 6th February 2024 I commenced an investigation into the death of John
Francis HOWLETT. The investigation concluded on the 13th August 2024 and the
conclusion was one of Narrative: Died from exacerbation of chronic obstructive
pulmonary disease contributed to by frailty due to dehydration and poor
nutritional status. The medical cause of death was 1a) Infective exacerbation
of chronic obstructive pulmonary disease II) Frailty
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CIRCUMSTANCES OF THE DEATH
John Francis Howlett had severe chronic obstructive pulmonary disease. He was
placed at The Lakes Care Home due to his severe chronic obstructive pulmonary
disease. He required oxygen and was bedbound. He became increasingly frail
whilst at The Lakes with poor nutrition and fluid intake. He developed an
infection and was admitted to Tameside General Hospital. He was treated but
despite the treatment he continued to decline as a consequence of the
exacerbation of his underlying chronic obstructive pulmonary disease and
frailty. He died at Tameside General Hospital on 31st January 2024.
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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.
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The MATTERS OF CONCERN are as follows. –
1. The inquest heard that on arrival at A and E at Tameside Hospital Mr
Howlett spent 22 hours in a corridor despite suffering from an infection
and the distress that this caused. The inquest was told that this was due
to the demands on the department and the challenges of moving
patients onto wards due to capacity issues. The inquest was told that
this was not unique to that particular day or indeed to the hospital and
was the picture across the country at that time.
2. The evidence before the inquest indicated that the care home in
question had been of concern in relation to the care offered to residents
for some time. It was indicated that action plans were in place
particularly in relation to safeguarding concerns given the vulnerability
of residents. However despite those steps being in place and the
concerns the systems were not in place at the care home to robustly
monitor his nutritional status and fluid intake. He became increasingly
frail with decreased physiological reserves as a consequence.
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ACTION SHOULD BE TAKEN
In my opinion action should be taken to prevent future deaths and I believe you
have the power to take such action.
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YOUR RESPONSE
You are under a duty to respond to this report within 56 days of the date of this
report, namely by 1st November 2024. I, 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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COPIES and PUBLICATION
I have sent a copy of my report to the Chief Coroner and to the following
Interested Persons namely
on behalf of the family, who may
find it useful or of interest.
I 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.
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Alison Mutch
HM Senior Coroner
06/09/2024
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