Carl Owston: Prevention of future deaths report
Hospital Death (Clinical Procedures and medical management) related deaths
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Date of report: 18/12/2023
Ref: 2023-0542
Deceased name: Carl Owston
Coroner name: Gareth Jones
Coroner Area: West Sussex, Brighton and Hove
Category: Hospital Death (Clinical Procedures and medical management) related deaths
This report is being sent to: Department of Health and Social Care
| REGULATION 28 REPORT TO PREVENT DEATHS | |
|---|---|
| THIS REPORT IS BEING SENT TO: 1 Rt Honourable Victoria Atkins Secretary of State for Health & Social Care | |
| 1 | CORONER I am Gareth JONES, Assistant Coroner for the coroner area of West Sussex, Brighton and Hove |
| 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 19 January 2023 I commenced an investigation into the death of Carl Anthony OWSTON aged 34. The investigation concluded at the end of the inquest on 18 December 2023. The conclusion of the inquest was that: Carl Owston died on the 10th of January 2023 at his home[REDACTED] from sudden unexplained death in alcohol misuse with steatosis and steatohepatitis. |
| 4 | CIRCUMSTANCES OF THE DEATH Carl Owston died on the 10th of January 2023 at his home [REDACTED] from sudden unexplained death in alcohol misuse with steatosis and steatohepatitis. |
| 5 | CORONER’S CONCERNS During the course of the investigation my inquiries revealed matters giving rise to concern. In my opinion there is a risk that future deaths could 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) Mr. Owston had a Care Package commissioned for him by Brighton and Hove City Council. They were unable to find a Care provider willing to provide the service due to a shortage of care providers and carers nationwide. The lack of carers and care providers could well lead to people in future not receiving the care they need with fatal results. |
| 6 | ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you (and/or 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 February 12, 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. |
| 8 | COPIES and PUBLICATION I have sent a copy of my report to the Chief Coroner and to the following Interested Persons [REDACTED] – Arch Healthcare [REDACTED] – Mother [REDACTED] – Father [REDACTED] -Sussex Partnership NHS Foundation Trust [REDACTED] – St Mungo’s [REDACTED] – Brighton & Hove City Council I am also under a duty to send a copy of your response to the Chief Coroner and all interested persons who in my opinion should receive it. I may also send a copy of your response to any person who I believe may find it useful or of interest. 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. |
| 9 | 18/12/2023 Gareth JONES Assistant Coroner for West Sussex, Brighton and Hove |