Elizabeth Agbejimi: Prevention of future deaths report
Hospital Death (Clinical Procedures and medical management) related deaths
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Date of report: 06/07/2023
Ref: 2023-0232
Deceased name: Elizabeth Agbejimi
Coroner name: Paul Cooper
Coroner Area: Lincolnshire
Category: Hospital Death (Clinical Procedures and medical management) related deaths
This report is being sent to: REDACTED
| REGULATION 28 REPORT TO PREVENT DEATHS | |
|---|---|
| THIS REPORT IS BEING SENT TO: [REDACTED] | |
| 1 | CORONER I am Paul COOPER, HM Assistant Coroner for the coroner area of Lincolnshire |
| 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 06 July 2021 I commenced an investigation into the death of Elizabeth Oluwatofunmi AGBEJIMI aged 22. The investigation concluded at the end of the inquest on 13 June 2023. The conclusion of the inquest was that: The deceased died on 27th June 2021 at Lincoln County Hospital, Greetwell Road, Lincoln following a multiple falls that the pathologist identified as a direct cause of death. |
| 4 | 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) [REDACTED] gave evidence that following a venous blood gas sample undertaken on 12th June 2021 which showed a significant respiratory abnormal acidosis reading but no further investigation was undertaken. The deceased died 2 weeks later of a respiratory condition. Is this a training/communication issue? |
| 5 | 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. |
| 6 | YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by August 09, 2023. 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. |
| 7 | COPIES and PUBLICATION I have sent a copy of my report to the Chief Coroner and to the following Interested Persons ULHT 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. |
| 8 | 06/07/2023 Paul COOPER, HM Assistant Coroner for Lincolnshire |