Prevention of Future Deaths reports · 2014
Regulation 28 report to prevent future deaths, reference 2014-0115, written 14 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 | 14 Mar 2014 |
|---|---|
| Reference | 2014-0115 |
| Deceased | Michael Tarratt |
| Coroner | Lydia Brown |
| Coroner area | Leicester City & South Leicestershire |
| Category | Community health care and emergency services related deaths |
| Organisation named | Leicestershire Partnership NHS Trust |
| 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 (1) REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: 1. Dr Peter Miller, Chief Executive, Leicestershire Partnership NHS Trust 2. 1 CORONER I am Lydia Brown, assistant coroner, for the coroner area of Leicester City and South Leicestershire. 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 12 February 2014 I commenced an investigation into the death of Michael Anthony Tarratt DOB 3 January 1968. The investigation concluded at the end of the inquest on 10 March 2014. The cause of death was multiple drug toxicity and my conclusion was this was an accidental death. 4 CIRCUMSTANCES OF THE DEATH Mr Tarratt had a long known history of poly drug and alcohol abuse, and was receiving treatment for his opioid dependence. He was prescribed methadone to assist with withdrawal. It appeared that Mr Tarratt was motivated to try and reduce his dependency and seemed to be positive and forward thinking at the time of his death. He was seeing his GP and drug worker regularly in the months leading up to his death. Mr Tarratt was found deceased at his home address from the effects of multiple drug toxicity; there was no evidence of intent to take his own life. 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) Despite Evidence from the Drug and Alcohol team that it was appropriate to update the relevant GP every 3 months, or at least every 6 months, it was accepted on this occasion that no contact had been made for 18 months. Consideration should be given to more regular contact between the services providing treatment. (2) Despite Evidence that the GP prescription of tramadol (for knee pain) was inappropriate for an opiate dependent patient, no contact was made with the GP surgery 1 and it was left to the patient to tell his GP. There was no evidence to suggest that Mr Tarratt did this. Consideration should be given to routine exchange of information regarding prescriptions between services, to avoid one agency counter-acting the treatment of the other. Consideration should be given to the appropriateness of asking the patient to be responsible for this communication. 6 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. 7 YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 9th May 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 – (father) (brother) Medical Director, NHS England for Leicestershire and Lincolnshire area who may find it useful or of interest. 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] 2 3
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.
From the Executive Office Direct dial: 2 May 2014 Leicestershire Partnership NHS Trust A University Teaching Trust Lakeside House 4 Smith Way Grove Park Enderby Leicester LE19 1SS Tel: 0116 295 0030 Fax: 0116 295 0842 RIC 7 MAY 2014 Mrs L Brown RECEIVED H M Assistant Coroner Leicester City & South Leicester The Town Hall Town Hall Square Leicester LE1 9BG Dear Mrs Mason Re. Michael Anthony Tarratt Thank you for your letter dated 14" March 2014, with the enclosed Regulation 28: Report to Prevent Future Deaths. | would like to reassure you that Leicestershire Partnership NHS Trust has carefully considered the concerns you have raised, and put actions in place to respond to them. Your concerns | am aware that you are concerned that: 1. Despite evidence from the Drug & Alcohol team that it was appropriate to update the relevant GP every 3 months, or at least every 6 months, it was accepted on this occasion that no contact had been made for 18 months. Consideration should be given to more regular contact between the services providing treatment. 2. Despite evidence that the GP prescription of Tramodol (for knee pain) was inappropriate for an opiate dependant patient, no contact was made with the GP surgery and it was left to the patient to tell his GP. There was no evidence to suggest that Mr Tarratt did this. Consideration shouid be given to routine exchange of information regarding prescriptions between services, to avoid one agency counter- acting the treatment of another. Consideration should be given to the appropriateness of asking the patient to be responsible for this communication. Action Taken A notification by way of urgent memo by email has been sent to all members of the Drug & Alcohol team that the agreed standard for communication and correspondence with patients’ GPs is that contact must be made with the GP: ¢ After the initial assessment; this will be a summary of the structured treatment plan. www. leicspt.nns.uk Chair: Professor David Chiddick CBE Chief Executive: Dr Peter Miller ss Moy, re = = IW % e ¢ Every three months as a minimum, or more often, if there has been a change to the treatment plan or a risk needs to be communicated « Atthe end of contact when the patient is discharged from treatment The Leicester Recovery Partnership's working draft Standard Operating Protocol (SOP) is under review and due for publication within the next few weeks. In relation to GP communication the SOP will state ¢ GP letters Structured Treatment For GPs that refer their patients to LRP who are in drug or alcohol structured treatment we must send an assessment summary letter written by the assessor, the exception being when the comprehensive assessment has been completed in open access/duty the assessment summary should then be completed by the RN or EP taking the case on after the first face to face appointment. If the service user does not attend this appointment we must still send a summary and advise that we will be offering further appointments. We must send GP review update letters every 3 month as a minimum or before if there is a change or risk and then at completion of treatment. Open Access/Tier 2 We will not routinely send GP assessment summaries or updates for these service users but if we feel we need to liaise/involve their GP at any other point in treatment we need to discuss with the service user, obtain consent and send an assessment summary or update letter | enclose a copy of the standard GP letter templates which have been reviewed and now K include prompts to ensure detailed updates are sent. These are due to be uploaded as part of the configuration with SystmOne within the next 14 days. The subsequent phase of work that will be completed by June 30” 2014 at the latest will include prompts and reminders to practitioners when GP updates are due A case note audit is due to take place within the next 14 days and will include a review of GP correspondence. Audits will be completed every 6 months thereafter. This matter has also been discussed at the Operational Managers meeting to highlight the need to include in staff supervision any training requirements or ongoing monitoring. It will also be included on the agenda of the next Neighbourhood Team meeting Please be reassured that Leicester Recovery Partnership takes ownership for ensuring exchange of information with GPs and the service user is not responsible for this communication Yours sincerel Dr Peter Miller Chief Executive Chair: Professor David Chiddick CBE Chief Executive: Dr Peter Miller
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