Eleanor Curley-Bennett: Prevention of Future Deaths Report
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Date of report: 20/12/2024
Ref: 2024-0705
Deceased name: Eleanor Curley-Bennett
Coroners name: Emma Serrano
Coroners Area: Staffordshire
Category: Child Death (from 2015)
This report is being sent to: Festimed
| REGULATION 28 REPORT TO PREVENT FUTURE DEATHS | |
|---|---|
| THIS REPORT IS BEING SENT TO: Festimed – Event Medical Provision Company. | |
| 1 | CORONER I am Emma Serrano, Acting Senior Coroner of Staffordshire. |
| 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 the 20 August 2023, I commenced an investigation into the death of Eleanor Curley-Bennett. The investigation concluded at the end of the inquest on 9 December 2024. The conclusion of the inquest was a narrative conclusion. The cause of death was: 1a) Positional Asphyxia |
| 4 | CIRCUMSTANCES OF THE DEATH i) Eleanor Curley-Bennett, 3 weeks old, was in a baby carrier with her mother, on the 18 Augusdt 2023. She was at a local, family friendly, music festival. Her mother realised something was wrong and that Eleanor Curley-Bennett, has stopped breathing. ii) She was taken to Festimed, who provided medical care for the music festival. The carried out basic life support on Eleanor Curley-Bennett, before ad during the ambulance journey to the Princess Royal Hospital, Shropshire, where she passed away in the early hours of the morning the following day, the 19 August 2023. iii) During evidence it was disclosed that Festimed did not carry the correct basic life support equipment, in the correct sizing for a baby of Eleanor Curley-Bennet’s age. Specifically. a) oropharyngeal airway; b) i-gel airway; and c) Tracheal tube. It was disclosed that there was no intubation equipment available. It was disclosed that there were no prefilled, diluted, adrenaline that would be suitable to be used on a patient of Eleanor Curley Bennetts age. |
| 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. – i) The lack of availability of the equipment and adrenaline described above |
| 6 | ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you 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 7 February 2025. 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 family of Eleanor Curley-Bennett. 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. |
| 9 | 20 December 2024 Miss Emma Serrano Acting Senior Coroner Staffordshire |