Prevention of Future Deaths reports · 2014
Regulation 28 report to prevent future deaths, reference 2014-0044, written 31 Jan 2014. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 31 Jan 2014 |
|---|---|
| Reference | 2014-0044 |
| Deceased | Lee Bonsall |
| Coroner | Jonathan Layton |
| Coroner area | Carmarthenshire & Pembrokeshire |
| Category | Service Personnel related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 2 |
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. Secretary of State for Health 1 CORONER I am Jonathan Mark Layton senior coroner, for the coroner area of Carmarthenshire and Pembrokeshire. 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 6th March 2012 I commenced an investigation into the death of Lee Jay Bonsall then aged 23. The investigation concluded at the end of the inquest on 31st January 2014. The conclusion of the inquest was a narrative verdict namely that the deceased had suspended himself by a ligature from a bannister railing at his home address on 3rd March 2012 but the question of intent remains unclear. The medical cause of death was asphyxia by hanging. 4 CIRCUMSTANCES OF THE DEATH (1) Mr Bonsall had joined the Army at the age of 17 and had served in Afghanistan. During his tour of Afghanistan he witnessed the death of a close friend. (2) An army psychiatrist subsequently deemed Mr Bonsall temperamentally unsuitable for service. He was discharged from the Army in September 2007. (3) Mr Bonsall continued to suffer from depression. He relocated to West Wales and registered with a surgery in 2010. After an assessment he was prescribed citalopram. He later renewed his prescription which his GP put on repeat prescription. This is contrary to good practice guidelines. (4) His GP considered counselling as an alternative to citalopram but did not refer Mr Bonsall for psychotherapy as there was a ten month waiting list. (5) Mr Bonsall was found hanging from a bannister rail at his home address by his wife on 3rd March 2012. 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) That citalopram was given on repeat prescription which is contrary to guidelines. It may well be that awareness of these guidelines needs to be raised to ensure that GPs are aware that citalopram should not be given on 1 (2) The ten month waiting times for psychotherapy effectively means that this is not a viable alternative to anti-depressant medication and it might well be that a review of these waiting times is appropriate. 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 the 28th March 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 Persons: DAC Beachcroft LLP Portwall Place Portwall Lane Bristol BS99 7UD Defence Inquest Unit Directorate of Judicial Engagement Policy 2nd Floor Zone 5 IDL 432 Ramilies Building Marlborough Lines Monxton Road Andover Hants SP11 8HJ 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 31st January 2014 Signed: 2
2 responses published against this report on judiciary.uk. A response is a body's written reply to the coroner's concerns; publication is at the discretion of the Chief Coroner's office, so an absent response does not mean nobody replied.
From the Rt Hon Jeremy Hunt MP Secretary of State for Health | @ | Department of H ealth Richmond House 79 Whitehall London POCI_839556 SIIA 2NS Tel: 020 7210 3000 Mr J Layton Mb-sofs@dh.gsi.gov.uk Senior Coroner Coronetr’s Office Town Hall Hamilton Terrace Milford Haven Pembrokeshire, SA73 3JW 31 MAR ants Den babs, Thank you for your letter following the inquest into the death of Lee Bonsall. In your report you conclude that the medical cause of death was asphyxia by hanging. I was very sorry to read of the events that led to the death of Mr Bonsall and wish to extend my sincere sympathies to his family. I understand Mr Bonsall had been in the army from the age of 17 and served in Afghanistan. During his service he witnessed the death of a close friend. He was discharged from the army in September 2007 after being found temperamentally unsuitable for service. He continued to suffer depression, relocated to West Wales and registered with a surgery there in 2010. His GP assessed him and prescribed citalopram. He had a repeat prescription for this drug. His GP considered counselling but did not refer Mr Bonsall for psychotherapy as there was a 10 month waiting list in that area of Wales. Mr Bonsall was found hanging by a ligature from a bannister rail at his home address on 3 March 2012. You raise the following matters of concern: e That citalopram was given on repeat prescription contrary to guidelines. You suggest that awareness of these guidelines needs to be raised so that GPs are aware that this drug should not be given on repeat prescription. e The ten month waiting time for psychotherapy effectively means it is not a viable alternative to anti-depressant medication. You suggest that a review of these waiting times is appropriate. As these tragic events took place in Wales and Mr Bonsall was under the care of the Welsh health service, you will appreciate that I cannot comment on matters that are the responsibility of the Welsh Government. I therefore strongly recommend that your report is brought to the attention of the Welsh Assembly. The Minister for Health and Social Services, Mark Drakeford AM, can be contacted at the following address: Welsh Government 5th Floor Ty Hywel Cardiff Bay CF99 INA However, it may be helpful if I explain the situation in England. In England there are in general no national restrictions on which medicines can be prescribed under repeat dispensing arrangements. The exception is scheduled drugs or controlled drugs within the meaning of the Misuse of Drugs Act 1971. Citalopram does not fall within this category. Responsibility for prescribing, including repeat prescribing, rests with the prescriber who has clinical responsibility for that particular aspect of a patient’s care. This includes considering the suitability of prescribing a particular medicine for a particular patient in light of individual circumstances. In England it is the responsibility of local primary care organisations to ensure that adequate controls are in place. They may therefore issue advice to GPs on repeat prescribing mechanisms. Comprehensive guidance is available to professionals about prescribing, including, for example, repeat prescribing issues, prescribing for certain categories of patient (including mental health) and prescribing of particular types of drugs, including anti-depressants. The National Institute for Health and Care Excellence (NICE), the General Medical Council and the British Medical Association have all produced guidance that specifically addresses assessing the risk of prescribing a particular medication for individuals at risk of self-harm. There is also specific product information available for citalopram itself covered in the manufacturer’s Product Information Leaflet (PIL) and the Summary of Product Characteristics. Relevant extracts from these sources are attached at Annex A. However, you will note that none of them specifically refers to repeat prescribing of citalopram. O epartment of Health Although your letter mentions guidelines, we cannot therefore establish exactly what you are referring to. I would look into this matter further if you could supply the information and if it falls within my remit. Likewise, on waiting times, the situation in England is that access to services, and the waiting times for those services, for people with mental health problems is unfortunately sometimes longer than for physical health services. Ensuring that mental health in England is treated equally with physical health means, for example, ensuring that people do not experience excessively long waits for treatment. The Department and NHS England are committed to ending this imbalance. We believe that it is vital to develop and implement new access and waiting time standards to have true parity of esteem. We are committed to providing access to services and waiting times on a par with physical health. NHS England is therefore developing options to improve access and waiting times standards for mental health services. There will be a phased approach to implementation of revised standards starting from April 2015. Improving Access to Psychological Therapies (IAPT) is an NHS programme in England which supports the frontline NHS in implementing NICE guidelines for treating people suffering from depression and anxiety disorders. Despite the many success stories, the clear focus and the good progress that has been made to date, as IAPT expands new challenges emerge. The initial success of the programme in the provision of services to the adult population has led to a rise in demand as more people are offered this service. I hope that this response is helpful and I am grateful to you for bringing the circumstances of Mr Bonsall’s death to my attention. we oe) Ey — JEREMY HUNT ais | Department | of Health ANNEX A - PRESCRIBING GUIDANCE 1) Repeat prescribing General Medical Council guidance, Good Practice in Prescribing and Managing Medicines and Devices (2013) http://www.gmc-uk.org/guidance/ethical_guidance/14316.asp The section on repeat prescribing states: Repeat prescribing and prescribing with repeats 55. You are responsible for any prescription you sign, including repeat prescriptions for medicines initiated by colleagues, so you must make sure that any repeat prescription you sign is safe and appropriate. You should consider the benefits of prescribing with repeats to reduce the need for repeat prescribing. 56. As with any prescription, you should agree with the patient what medicines are appropriate and how their condition will be managed, including a date for review. You should make clear why regular reviews are important and explain to the patient what they should do if they: a. suffer side effects or adverse reactions, or b. stop taking the medicines before the agreed review date (or a set number of repeats have been issued). You must make clear records of these discussions and your reasons for repeat prescribing. 57. You must be satisfied that procedures for prescribing with repeats and for generating repeat prescriptions are secure and that: a. the right patient is issued with the correct prescription b. the correct dose is prescribed, particularly for patients whose dose varies during the course of treatment c. the patient’s condition is monitored, taking account of medicine usage and effects d. only staff who are competent to do so prepare repeat prescriptions for authorisation e. patients who need further examination or assessment are reviewed by an appropriate healthcare professional Jf. any changes to the patient’s medicines are critically reviewed and quickly incorporated into their record. 58. At each review, you should confirm that the patient is taking their medicines as directed, and check that the medicines are still needed, effective and tolerated, This may be particularly important following a hospital stay, or changes to medicines following a hospital or home visit. You should also consider whether requests for repeat prescriptions received earlier or later than expected may indicate poor adherence, leading to inadequate therapy or adverse effects. 59. When you issue repeat prescriptions or prescribe with repeats, you should make sure that procedures are in place to monitor whether the medicine is still safe and necessary for the patient. You should keep a record of dispensers who hold original repeat dispensing prescriptions so that you can contact them if necessary. Medical Protection Society Repeat prescribing for GPs: Care should be taken with any drug that is added to a repeat prescribing list. However, some drugs lend themselves more readily to a repeat prescribing approach, such as antihistamines, which require minimal levels of monitoring. Drugs that are not suitable for routine repeat prescribing include hypnotics, antidepressants and disease modifying agents, eg, methotrexate. 2) Use of anti-depressant drugs The British National Formulary contains comprehensive advice about the use and management of anti-depressant (AD) drugs and advises that: “patients should be reviewed every 1-2 weeks at the start of antidepressant treatment.” Guidance on the use and dosage of the specific AD drug, Citalopram is also included, ee Department of Health 3) Prescribing of Citalopram The Patient Information leaflet for Citalopram offers the following warnings and advice about duration of treatment: Warnings and precautions Citalopram Tablets should be taken with caution if you: e suffer from psychosis with depressive episodes, because the psychotic symptoms may increase. How long should you take Citalopram Tablets Your doctor will decide on the duration of treatment. An improvement in depressive symptoms can take at least 2 weeks after starting of treatment. Treatment should be continued for at least 4-6 months. If you don’t start to feel better after a couple of weeks, go back to your doctor who will advise you. The Summary of Product Characteristics (SPC) for Citalopram includes the requirement for monitoring if suicide is a potential: https://www.medicines.org.uk/emc/medicine/23861/SPC/Citalopram+20mg+Ta blets/#POSOLOGY Suicide/suicidal thoughts or clinical worsening Depression is associated with an increased risk of suicidal thoughts, self harm and suicide (suicide-related events). This risk persists until significant remission occurs. As improvement may not occur during the first few weeks or more of treatment, patients should be closely monitored until such improvement occurs. It is general clinical experience that the risk of suicide may increase in the early Stages of recovery. Other psychiatric conditions for which citalopram is prescribed can also be associated with an increased risk of suicide-related events. In addition, these conditions may be co-morbid with major depressive disorder. The same precautions observed when treating patients with major depressive disorder should therefore be observed when treating patients with other psychiatric disorders. Patients with a history of suicide-related events, or those exhibiting a significant degree of suicidal ideation prior to commencement of treatment are known to be at greater risk of suicidal thoughts or suicide attempts, and should receive careful monitoring during treatment. A meta-analysis of placebo-controlled clinical trials of antidepressant drugs in adult patients with psychiatric disorders showed an increased risk of suicidal behaviour with antidepressants compared to placebo in patients less than 25 years old. Close supervision of patients and in particular those at high risk should accompany drug therapy especially in early treatment and following dose changes. Patients (and caregivers of patients) should be alerted about the need to monitor for any clinical worsening, suicidal behaviour or thoughts and unusual changes in behaviour and to seek medical advice immediately if these symptoms present.
From the Rt Hon Jeremy Hunt MP Secretary of State for Health Department of H ea It h Richmond House 79 Whitehall London POC1_ 854254 SWIA 2NS Tel: 020 7210 3000 Mr J Layton Mb-sofs@dh.gsi.gov.uk Senior Coroner Coroner’s Office Town Hall Hamilton Terrace Milford Haven Pembrokeshire, SA73 3JW ~FMAY Mth Des be, lghs, Thank you for your further letter of 3 April 2014 in response to mine of 31 March 2014 concerning the death of Lee Jay Bonsall. Thank you also for clarifying the basis for your recommendation on the repeat prescription of citalopram. As I said in my earlier response to you, there are no national restrictions on the repeat prescribing of citalopram in England. The National Institute for Health and Care Excellence’s clinical guidelines for the treatment and management of depression in adults (CG90) state: “1.5.2.6 For people started on antidepressants who are not considered to be at increased risk of suicide, normally see them after 2 weeks. See them regularly thereafter, for example at intervals of 2 to 4 weeks in the first 3 months, and then at longer intervals if response is good. 1.5.2.7 A person with depression started on antidepressants who is considered to present an increased suicide risk or is younger than 30 years (because of the potential increased prevalence of suicidal thoughts in the early stages of antidepressant treatment for this group) should normally be seen after 1 week and frequently thereafter as appropriate until the risk is no longer considered clinically important.” While I would agree that one might therefore expect antidepressant medicines in most cases to be prescribed in accordance with these arrangements, NICE’s guidelines are not rules and do not restrict the prescribing, including the repeat prescribing, of such medicines. NICE’s clinical guidelines represent best practice and are based on the available evidence and developed through wide consultation. Prescribing and the management of individual cases, however, remain the clinical responsibility of the doctor concerned. NICE will be reviewing its guidelines on depression (CG90) in due course. I will copy this reply to NICE, including your prescribing concerns, so they can consider them for their next guideline review. I hope that this further response is helpful. en saw To Uw JEREMY HUNT
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