Evidence
Date of report: 30/08/2024
Ref: 2024-0474
Deceased name: Terence Clark
Coroners name: Graeme lrvine
Coroners Area: East London
Category: Hospital Death (Clinical Procedures and medical management) related deaths
This report is being sent to: Barts Health NHS Foundation Trust | Department of Health and Social Care
REGULATION 28 REPORT TO PREVENT FUTURE DEATHS | |
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THIS REPORT IS BEING SENT TO:
1. [REDACTED], Chief Executive Officer, Barts Health NHS Foundation Trust |
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CORONER
I am Graeme lrvine, senior coroner, for the coroner area of East London |
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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 and29 of the Coroners (lnvestigations) Regulations 2013. |
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INVESTIGATION and INQUEST
On 3rd November 2023 this court commenced an investigation into the death of Terence Harry Clark, aged 76. The investigation concluded at the end of the inquest on 27th August 2024 when the court returned a narrative conclusion. Mr Clarks medical cause of death was determined as; a Aspiration Pneumonia |
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CIRCUMSTANCES OF THE DEATH
Terence Harry Clark was 76-year-old man with considerable co-morbidity, including a compromised swallow, dysphagia. Mr Clark was admitted to hospital by ambulance on the evening of 26th October 2023 with difficulty in breathing. Mr Clark was diagnosed with bilateral aspiration pneumonia. The deceased was admitted and treated with anti-biotics. |
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CORONER’S CONCERNS
During the course of the inquest the evidence revealed matters giving rise to concern. ln my opinion there is a risk that future deaths could occur unless action is taken. ln the circumstances it is my statutory duty to report to you. The MATTERS OF CONCERN are as follows. – A. Despite Mr Clark having been subject to a nil-by-mouth order for 24 hrs prior to B. The Trust conducted a patient safety investigation into the circumstances |
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ACTION SHOULD BE TAKEN ln my opinion action should be taken to prevent future deaths and I believe you IAND/OR 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 25th October 20241, the coroner, may extend the period. |
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COPIES and PUBLICATION
I have sent a copy of my report to the Chief Coroner and to the following lnterested Persons the family of Mr Clark, the Care Quality Commission and to the local Director of Public Health who may find it useful or of interest. |
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30/08/2024 SIGNED BY THE CORONER |
The post Terence Clark: Prevention of Future Deaths Report appeared first on Courts and Tribunals Judiciary.
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