Mary Johnson

Date of report: 1 February 2019 Ref: 2019-0495 Deceased name: Mary Johnson Coroners name: Hugh Bricknell Coroners Area: Herefordshire Category: Hospital Death (Clinical Procedures and medical management) related deaths This report is being sent to: Wye Valley NHS Trust

HG Mark Bricknell Senior Coroner for County of Herefordshire

REGULATION 28 REPORT TO PREVENT FUTURE DEATHS

THIS REPORT iS BEING SENT TO: Mr Glen Burley, Chief £ tive, Wye Valley NHS Trust

CORONER

tam Hugh Gregory Mark Bricknell, Senior Coroner for County of Herefordshire

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. http:/Awww.legistation.gov.uk/ukpga/2009/25/schedule/5/paragraph/7 hito:/Awww.legislation.gov.ul/uksi/2013/1629/part/7/made 3 INVESTIGATION and INQUEST On the 1st day of August 2018 | commenced an investigation into the death of Mary Bertha Johnson 4 CIRCUMSTANCES OF THE DEATH Mrs Mary Bertha Johnson died on the 25th July 2018 at the County Hospital, Hereford. Mrs Johnson had fallen on the 20th July 2018 causing a periprosthetic fracture of the femur. 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. — [BRIEF SUMMARY OF MATTERS OF CONCERN] (1) A lack of communication between staff highlighted issues concerning: (a) the feeding of patients prior to operation (b) adherence to the Consultant's instructions regarding the provision of medication prior to operation

(2) It was suggested that the availability of porters determined the ability of the hospital theatres to carry out operations

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ACTION SHOULD BE TAKEN

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

YOUR RESPONSE

You are under a duty to respond to this report within 56 days of the date of this report, namely by the 29th March 2019 |, 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 sent a copy of my report to the Chief Coroner and to the following interested Persons: ns Operational Medical Director, Wye Valley NHS Trust.

| 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.

Dated 9 im Leb, acey old

. a A Signature. WV fen Aasd for County of Héréfgrdshire V

HG. Bkegue CORON FR

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