Prevention of Future Deaths reports · 2014
Regulation 28 report to prevent future deaths, reference 2014-0085, written 28 Feb 2014. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 28 Feb 2014 |
|---|---|
| Reference | 2014-0085 |
| Deceased | Richard White |
| Coroner | Crispin Oliver |
| Coroner area | County Durham & Darlington |
| Category | Other related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: 1. Dr John Elliston MBE, Chief Executive of the 700 Club, Darlington, Co Durham 1 CORONER I am Crispin Oliver, Assistant Coroner, for the Coroner area of County Durham and Darlington 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. (see attached sheet) 3 INVESTIGATION and INQUEST On 14 June 2013 I commenced an investigation into the death of Richard Philip WHITE. The investigation concluded at the end of the inquest on 5th February 2014. The conclusion of the inquest was findings were that Mr White died at Darlington Memorial Hospital on 9th June 2013, having previously taken an overdose of cyclizine at 700 Club, Hope House, Darlington (“Hope House”) and the conclusion of the Inquest was that he had died as a result of misadventure. 4 CIRCUMSTANCES OF THE DEATH a. Richard White became a resident at Hope House on or about 15th or 16th May 2013. 700 Club is a charity which provides at Hope House, and St George`s Hall, supported hostel accommodation and support for vulnerable people with substance misuse issues or alcohol issues. On the 17th May Richard received a prescription for 21 cyclizine 50 mg tablets at Neasham Road Surgery, Darlington. On 6th June 2013 he received a prescription for 84 cyclizine 50 mg tablets plus 10 zopiclone 7.5 mg tablets at the same surgery. The zopiclone is a “sleeping pill” and the cyclizine was prescribed in relation to nausea. Richard had a history of previous attempts at self-harm, including one shortly before being admitted to Hope House, of which the staff there were aware at time the prescriptions were obtained. b. At the appointment on 6th June 2013 with and his Support Worker from 700 Club, Mr White attended with his mother, During the gave evidence that she believed all of the medication she prescribed, Inquest cyclizine and zopiclone, would be kept secure by Hope House staff andthat had she known that this was not the case she would probably not have prescribed as much of the cyclizine as she did. gave evidence that he was concerned only about the “sleeping pills” (zopliclone) being looked after by Hope House staff. had the impression that the medication would be gave evidence that she, like kept secure by Hope House. manager of Hope House, gave evidence that the policy of 700 Club is that medication is self-administered by the residents and only secured upon the request of the residents themselves and retained with their consent. She stated that she did not known where this policy was written down or kept. attended the pharmacy c. After the appointment Mr White, his mother and where the medication was collected. took the zopiclone and placed it in the office of Hope House for Richard subsequently to access it. Mr White took possession of the cyclizine, from the outset. On 9th June 2013 Richard White presented to staff at Hope House and announced that he had taken 104 cyclizine tablets and 7 or 8 zopiclone tablets. In spite of the best endeavours of the staff and paramedics, he subsequently died as a result of cyclizine toxicity. 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 the policy of Hope House with regard to the administration and holding by when she wrote the staff of medication was not made known to prescriptions; 2) That the policy was not provided in a protocol, or policy statement, to , or indeed, and 3) That no such protocol or policy statement was available. 6 ACTION SHOULD BETAKEN In my opinion action should be taken to prevent future deaths and I believe you,on behalf of the 700 Club 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 25th April 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 I have also sent it to Chair of the Board of Trustees of the 700 Club, Manager of the 700 Club), the Neasham Road Surgery, Darlington) and Neasham Road Surgery) who may find it useful or of interest. (Richard White`s Mother), (Service (care of (Practice Manager of 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 Dated…………………………… Signed by ……………………..
1 response 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.
700 CLUB Head Office The Grange Centre Grange Road Baptist Church — Darlington DL1 5NH Tel: 01325 366397 FAX: 01325 288413 www. 700club.org.uk Re. Residents of Hope House Hostel on Grange Road, St Georges Hall on Elmfield Street and The Lodge on Victoria Hill, Darlington Dear Colleague | am writing to your practice on behalf of the 700 Club to remove any ambiguity relating to the storage or administration of medication by our organization. We do not, as a matter of policy, either store medication on the behalf of our clients, nor do we administer medication to clients. Prescriptions issued to our clients by your practice should take the above information into account, particularly if that client is vulnerable and there is a concern that the client may use that medication inappropriately (self-harm, selling on). The responsibility for safeguarding clients in regard to prescribed medication lies with GP's. Occasionally a client will hand their medication to us because they feel tempted to take more than prescribed. If this does occur, we will receive it but will not return the medication to the client without the direct authority of the prescribing GP. Where that authority is provided, all of the surrendered medication will be handed back to the client, and not merely sufficient medication for any particular dose or day. Again, | reiterate, we do not administer. If the GP declines to give consent for all of the medication to be returned to the client then staff are instructed to return the medication to the nearest chemist and direct their client back to their GP. | hope this letter clarifies our position as an organization. Yours sincerely Dr John Elliston CEO 700 Club 700 Club. A charitable company limited by guarantee, Company No. 3191544. Charity No. 1056192. Registered in England and Wales. Registered Office and address for service as above. Members of Bassac, BECON, NHF and Darlington Housing Action AUD) Sune, f 8h ff 2 XN 4 EMPLOYER “‘go10 1509001 owsas 18001 REGISTERED FIRM REGISTERED FIRM REGISTERED FIRM Medication Administration Policy The 700 Club believe that clients should be encouraged towards independence including managing their own medicines in a safe and effective manner. It is therefore the policy of the 700 Club that no medication is administered. Medication Administration is the actual giving of medication and may involve: e storing the medication e opening the medication container e removing the prescribed dosage e prompting the client to take the medication. General prompt charts that are developed in partnership with the clients, are part of the support plan, and are kept by the clients are acceptable. e and giving the medication to the client as per instructions. Amember of staff should not agree with either a client or any third party (parent, GP) to store or keep medication. The one exception to this would be when a client hands over medication to a member of staff to prevent self- harm. In this case the medication should be returned to the client only with the express permission of the prescribing GP. If this permission is granted, all of the surrendered medication should be handed back to the client, and not merely sufficient medication for any particular dose or day. If that permission is not given, the medication should be returned to the chemist and the client encouraged to make a new appointment with the prescribing GP. POLICY REVIEW The 700 Club will review this policy on an annual basis 700C\ub/Medication Administration and Support Policy/Mar 2014/Version 4
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