Prevention of Future Deaths reports · 2014
Regulation 28 report to prevent future deaths, reference 2014-0110, written 11 Mar 2014. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 11 Mar 2014 |
|---|---|
| Reference | 2014-0110 |
| Deceased | Teresa Lonergan |
| Coroner | Andrew Harris |
| Coroner area | London Inner (South) |
| Category | Community health care and emergency services related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | none published |
Text recovered by OCR from a scanned PDF. OCR is imperfect: check anything you rely on against the source PDF. Reproduced verbatim, including the scan's own layout.
Senior Coroner for London Inner South REGULATION 28 REPORT TO PREVENT FUTURE DEATHS Re: Teresa Lonergan, died 04.09.12, case ref 02145-12 THIS REPORT IS BEING SENT TO: 1. Eltham Park Surgery, 46 Westmount Road, Eltham, SE9 1JE 1 CORONER | am Andrew Harris, senior coroner for the jurisdiction of London Inner South 2 | CORONER’S LEGAL POWERS | 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 12 September 2012, | opened and inquest into the death of Teresa Lonergan, aged 73 years. The inquest concluded on 18" February 2014. | concluded that the deceased had taken her own life. 4 | CIRCUMSTANCES OF THE DEATH Mrs Lonergan was found in her home and beyond resuscitation and certified dead at 10.10 on 04.09.12. She suffered considerable pain from worsening rheumatoid arthritis and had expressed an intention to take her life. She had hoarded prescribed morphine and taken an overdose. 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) At the scene the following bottles of morphine were found: 1 100 mI bottle 10mg/S5mls 10% remaining, dated 21/02/12 4 100 mi bottle 10mg/5m! 30% remaining, dated 09/03/12 4 100 ml bottle 10mg/5m! 33% remaining, dated 08//05/12 1 100 mi bottle 10mg/5mls 75% remaining ? date 1 100 mi bottle 10mg/5ml, full, dated 13/07/12 and 3 loose strips of 10mg Zomorph with 23 of 28 remaining It was calculated that @f the liquid morphine alone was considered there was 340mg available. The pathologist advised that 100 to 200mg would probably be sufficient to cause a fatality. (2) She was a retired matron. She was visited twice daily by her care worker, who opened her bottles for her as she was not able to do so herself. She did not report any medical instructions from doctors about administration or monitoring. Her GP issued repeat prescriptions of: 40mg Zomorph MR3 capsules 1 bd (issue up to 120), last issued 03/05/12 Morphine sulphate 10mg/5ml qds prn (issue up to 200mls)last issued 11/07/12. This was in addition to regular benzodiazepines and other non controlled analgesia. It was reported that she was visited several times a year by the surgery and kept in contact on the phone. There was no report of any monitoring of her consumption of controlled drugs, but the evidence from the general practice was read. She appeared to continue to draw prescriptions but not consume them as prescribed, thus building up a hoard, and providing the means for a deliberate overdose to be taken. ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and | believe you and your practice have the power to take such action. | request that you and/ the practice should review prescribing and monitoring of controlled drugs and consider whether any action is appropriate to minimize the risk of hoarded controlled drugs in future. YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by Tuesday April 29" 2014. |, 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. COPIES and PUBLICATION | have sent a copy of my report to the Chief Coroner and to the following Interested Persons RS 2:12 niece | have also sent it Chief Officer and ecomee eem Medicine Management at Greenwich Clinical Commissioning Group an Managing Director NHS South London Commissioning Support Unit who may find it useful or of interest. lam 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 Cgroner. ce DATE ‘SIGNED BY CORONER
See every Prevention of Future Deaths report matching Community health care and emergency services related deaths, and how often a new one appears.
What would an alert for this have sent me? Search the full text
Free to try — the preview shows the real matches and how many arrived in the last 12 months. Your first email alert is free.
These reports are published by the Chief Coroner's office at judiciary.uk and are © Crown copyright. The text here is reproduced from the published PDF so it can be searched. If something on this page is wrong, or you are a person named in it and want it reviewed, email drcjar@gmail.com and we will act promptly.