Prevention of Future Deaths reports · 2013
Regulation 28 report to prevent future deaths, reference 2013-0289, written 1 Nov 2013. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 1 Nov 2013 |
|---|---|
| Reference | 2013-0289 |
| Deceased | Joanne Manning |
| Coroner | Nadia Persuad |
| Coroner area | London |
| Category | Community health care and emergency services related deaths |
| Organisation named | North East London NHS Foundation Trust |
| Source | judiciary.uk record · original PDF |
| Responses published | none published |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
REGULATION 28: REPORT TO PREVENT FUTURE DEATHS
REGULATION 28 REPORT TO PREVENT FUTURE DEATHS
THIS REPORT IS BEING SENT TO:
1.
2.
Chief Executive, The Practice, Rose House, Bell Lane
Office Village, Bell Lane, Little Chalfont, Amersham, Bucks, HP6 6FA
Legal Counsel and Company Secretary, The Practice,
Rose House, Bell Lane Office Village, Bell Lane, Little Chalfont,
Amersham, Bucks, HP6 6FA
1
CORONER
I am Nadia Persaud, assistant coroner, for the coroner area of East 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.
[HYPERLINKS]
3
INVESTIGATION and INQUEST
On 1 November 2013 I resumed and concluded an inquest into the death of Joanne
Manning (date of birth 29 April 1964 – aged 49). The investigation concluded at the end
of the inquest on 1 November 2013. The conclusion of the inquest was that Joanne
Manning had a history of poly-substance abuse, for which she received a prescription of
methadone. In the months leading up to her death she began to experience increasing
breathlessness and a diagnosis of asthma was confirmed. Her methadone was
continued at a relatively low dose of 25mg/ml daily. The combination of her underlying
respiratory disease and the effects of the use of methadone and mirtazapine and the
presence of cocaine and morphine, caused her to suffer respiratory failure, from which
she died.
4
CIRCUMSTANCES OF THE DEATH
(1) Joanne Manning had suffered from poly-substance abuse for many years and
had received methadone treatment for many years. She had, in the past,
received doses of up to 80mg/mls. Her final dose was reduced to 25mg/ml as
the prescribing psychiatrist was aware, from the patient, that she was suffering
from asthma.
(2) If Ms Manning was non compliant with methadone, she would relapse to using
drugs of abuse. The methadone therefore had to be continued.
(3) In May 2012 she began to suffer from breathlessness and was seen by general
practitioners at The Practice in Loxford.
(4) A diagnosis of asthma was made in September 2012 by her general practitioner
and Ms Manning was commenced on clenil modulite and salbutamol inhalers.
(5) On 15 August 2012 Ms Manning presented with depression to the general
practitioner and was prescribed mirtazapine.
(6) Methadone was being prescribed by the psychiatric team and the general
practice were aware of this by clinic letters.
(7) Despite being aware of the patient receiving methadone, there was no evidence
that the general practitioners had taken the methadone into account when
treating the patient, or provided any advice to the patient in relation to the risks
1
(8) On the 29 August 2012 the psychiatrist prescribing the methadone requested
information from the general practitioner as to any further medication/treatment
that the patient was receiving.
(9) Despite the general practitioner considering that it was for the psychiatrist to
consider the risks of methadone in a patient suffering from asthma and to advise
the patient of the risks, there was no response to the psychiatrist’s request for
further information. The general practice did not confirm the diagnosis of
asthma or the treatment with mirtazapine. The psychiatrist could not therefore
make a fully informed assessment.
(10) Ms Manning died as a result of respiratory failure. On the balance of
probabilities, the respiratory failure was caused by the combination of
methadone, mirtazapine and the presence of cocaine and morphine.
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. –
(1) Methadone is to be used with caution in a patient suffering from asthma. In order for
the prescriber of methadone to exercise all due caution, they would have to be fully
informed of the patient’s diagnosis and treatment by other healthcare professionals
involved in the patient’s care.
(2) Evidence was heard that methadone should be used with caution in a patient who is
also receiving mirtazapine.
(3) The psychiatrist prescribing the methadone requested further information about the
patient’s medication and treatment from The Practice, Loxford. The letter from the
psychiatrist was in the general practice file. It was not however responded to.
(4) The general practitioner who gave evidence at the Inquest agreed that the
psychiatrist should have been fully informed, but she felt that the patient could tell the
psychiatrist about her diagnosis and treatment.
(4) The general practitioner was unable to comment on whether it would be appropriate
for a patient who often attended appointments intoxicated, to inform the psychiatrist of
key clinical information. It is my view that this would not be appropriate.
(5) Evidence was given at the Inquest that there was no procedure or policy in place to
ensure clear lines of communication between general practitioners to secondary care
providers of methadone. It was agreed by the general practitioner and psychiatrist that
such a policy/procedure would be desirable to protect patients in the future.
6
ACTION SHOULD BE TAKEN
In my opinion action should be taken to prevent future deaths and I believe you, The
Practice PLC, 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 6 January 2014. 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
2
Persons -
North East London NHS Foundation Trust. I have also sent it to the
Redbridge Clinical Commissioning Group who may find it useful or of interest. They
may wish to disseminate the learning to wider practices.
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
[DATE] [SIGNED BY CORONER]
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