Hunter Macmillan

Date of report: 24 October 2016 Ref: 2016-0375 Deceased name: Hunter Macmillan Coroners name: Chinyere Inyama Coroners Area: London (West) Category: Hospital Death (Clinical Procedures and medical management) related deaths This report is being sent to: Chelsea and Westminster Hospitals NHS Trust

REGULATION 28: REPORT TO PREVENT FUTURE DEATHS (1)

NOTE: This form is to be used after an inquest.

REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO:

CHIEF EXECUTIVE AT THE CHELSEA AND WESTMINSTER HOSPITALS NHS FOUNDATION TRUST

1 | CORONER

1am Chinyere Inyama, senior coroner for the coroner area of West London

2 | 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.

3 | INVESTIGATION and INQUEST

On 20" of November 2015 | commenced an investigation into the death of Hunter Jack Macmillan. The investigation concluded at the end of the inquest on 5" September 2016 with a narrative.

4 | CIRCUMSTANCES OF THE DEATH

Hunter Jack Macmillan was booked into the Urgent Care Centre at West Middlesex Hospital before, as a result of his condition, being taken to the Emergency Department at West Middlesex Hospital. He was not triaged in the Emergency Department for over 45 minutes by which time his condition had deteriorated.

5 | 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.

The MATTERS OF CONCERN are as follows. — Staffing levels in the Emergency Department were not sufficient to be able to follow

national (currently NICE Guideline, Sepsis:recognition, diagnosis and early management) or any local policy on treating suspected sepsis.

6 | ACTION SHOULD BE TAKEN

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

7 | YOUR RESPONSE

You are under a duty to respond to this report within 56 days of the date of this report, namely by 16" December 2016. 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.

COPIES and PUBLICATION

| have senta a of my report to the Chief Coroner and to the following persons: | |

and the parents of Hunter Jack Macmillan. | 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.

24" October 2016 SIGNED BY CORONER

Crryama