This report is being sent to: Cardiff Citu Council
REGULATION 28 REPORT TO PREVENT FUTURE DEATHS
THIS REPORT IS BEING SENT TO: The Chief Executive of Cardiff City Council, Director of Social Services, Cardiff City Council
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CORONER I am Rachel Knight Assistant Coroner, for the coroner area of South Wales Central.
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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 27 January 2021 I commenced an investigation into the death of Stella Ann JAMES . The investigation concluded at the end of the inquest on 13/06/2023.
The conclusion of the inquest was natural causes. Left Lobar Pneumonia Severe Malnutrition (BM1 12.8) Avoidant Restrictive Food Intake Disorder (ARFID) II Chronic Fatigue Syndrome
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CIRCUMSTANCES OF THE DEATH
These were recorded as Stella Ann James was aged 40 when she died at the Royal Glamorgan Hospital on 20th January 2021. Stella had a complex medical history over a 6 year period. Over time, she had stopped tolerating food orally, due to pain and distressing symptoms. Stella had been thoroughly investigated for every conceivable physical, Psychiatric and Psychological cause. There was no evidence of anorexia symptoms, but she did fit the criteria for ARFID (Avoidant Restrictive Food Disorder). took, to the point Stella was fed with a tube, but had restricted that she was malnourished and very underweight.
On 19 amount of food she January 2021, her parents rang 999 after finding her minimally conscious at home. She was admitted to hospital and had a severe pneumonia with sepsis which was treated, however her condition deteriorated and she died the next day.
The Inquest focused upon:- a. The diagnosis and treatment of Stella’s illness
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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 ta circumstances it is my statutory duty to report to you.
The MATTERS OF CONCERN are as follows.
(1) Stella appeared to meet the criteria as an ‘adult at risk of neglect avoidance and very low body weight, yet there was no apparent mec Services to be aware of Stella’s status. Stella was very secretive an when assessed months before her death, although it is noted that thi (2) Could there be a register to include a person in Stella’s position, whereby unannounced house visits from a social worker can be an option? Perhaps involving a mechanism for anonymous referral?
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ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you and your organisation 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 29th August 2023. 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 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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