Prevention of Future Deaths reports · 2014
Regulation 28 report to prevent future deaths, reference 2014-0141, written 31 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 | 31 Mar 2014 |
|---|---|
| Reference | 2014-0141 |
| Deceased | Deanne Smith |
| Coroner | Dr R N Palmer |
| Coroner area | South London |
| Category | Alcohol, drug and medication related deaths |
| Organisation named | Oxleas NHS Foundation Trust |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
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.
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H.M. Senior Coroner, South London Area
South London Coroner's Office
Saint Blaise Building, Bromley Civic Centre
Stockwell Close, Bromley BR1 3HU
Telephone 020-8313 1883 Fax 020-8313 3673
Coroners and Justice Act 2009; section 32; schedule 5, paragraph 7
The Coroners (Investigations) Regulations 2013 Regulation 28:
REPORT TO PREVENT FUTURE DEATHS
THIS REPORT IS BEING SENT TO:
41. Chief Executive, Bromiley Drug and Alcohol Service
2. Supervising Pharmacist, United Pharmacy, Croydon
CORONER
{am senior coroner for the coroner area of South London
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. Statutory
Instrument 2013 no.1629
INVESTIGATION and INQUEST
On 8" January 2013 | commenced an investigation into the death of Deanne Naomi
Smith, born on 29 May 1978 and who died on 8" January 2013. The investigation
concluded at the end of the inquest on 28" March 2014.
CIRCUMSTANCES OF THE DEATH
Deanne Smith was dependent on drugs. Because of concern about the high
dosage of medication she requested from her general practitioner, the GP referred |
her to the local Drug and Alcohol Dependency Unit. Deanne was assessed by
Bromley Drug and Alcohol Service, first on 23 February 2012 and again on 18
December 2012. Her treatment plan included supervised consumption of 70mg
of methadone daily which was to be changed to daily unsupervised consumption
after three consecutive drug-free urine samples. On 18 December 2012 Deanne
reported that she had relapsed and had been using £40-£60 heroin a day. The
treatment plan following this appointment was to commence on 30mls
methadone which was to be increased gradually to 50mls in line with titration
guidelines. Deanne was to be reviewed in 3 months time but died on 8" January
2013.
Deanne’s sister visited on 8" January 2013 but was unable to gain entry so called
emergency services. Deanne was pronounced dead at 09.50h. Police officers who
attended the scene found “approximately 9 x 50mls methadone bottles in the
room, about 7 of which were empty and 2 were full. ... 6 bottles were prescribed
to Deanne on 24.12.2012 and another 6 on 31.12.2012 these had been collected
Jrom United Pharmacy.”
CORONER’S CONCERNS
The evidence I heard at the inquest concerns me in that at times of public
holidays, such as Christmas and New Year, when the usual pharmacy is closed
for some of the days, an appreciable quantity of methadone is dispensed and
provided for the individual to use on days over the holiday period. When the
individual is dependent on opiates and is known to acquire opiates both legally
and illegally, it seems appropriate to question to wisdom of providing several
days’ supply at one time.
l invite the Drug and Alcohol Service and the Pharmacy to reconsider their
policies and procedures for the provision of methadone to drug-dependent
individuals at times of public holiday when the usual methods of provision are
suspended. If drug-dependent individuals are permitted to take away several
days’ supply in one visit, there must remain a risk of future deaths. Part of a
coroner’s duty at an inquest is to make a report such as this, intended to assist in
the prevention of future deaths.
ACTION SHOULD BE TAKEN
In my opinion action should be taken to prevent future deaths and | believe you or your
organisation has the power to take such action.
YOUR RESPONSE
You are under a duty to respond to this report within 56 days of the date of this report. |,
the coroner, may extend the period if requested to do so.
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 th i ner and to the mother of Deanne Smith
and to Deanne’s general practitioner of the Park Practice and to the Chief
Executive of Oxleas NHS Foundation Trust (Bracton Centre).
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 Coroner.
OR RN PALMER, H.M. CORONER
SOUTHERN JURISDICTION OF GREATER LONDON
ST BLAISE BUILDING
BROMLEY CIVIC CENTRE
STOCKWELL CLOSE
BROMLEY BR1 3UH
34°' March 2014
[SIGNED BY SENIOR CORONER]
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.
27 MAY 204 United Pharmacy 5 The Parade, Croydon RD Anerley. London. SE20 7AA Tel/Fax: 020 87788285 coroner's Office St Blaise Building Bromley. BR1 3UH Thank you for sending me the Prevention of Future Deaths Report. In response please find the following actions taken: 1. United Pharmacy’s pharmacists are already working closely with patient’s key special workers In order to exchange information on clients using the Bromley Drugs and Alcohol services in order to make sure patient’s are taking their medication on time. 2. We have regular meetings (at least twice yearly) with Bromley Drugs and Alcoho! services where we can openly discuss our concerns about the service with the prescribers. 3. For patients who have relapsed or not taking thelr medication on regular basis, we will encourage the services to use pharmacies that are open at weekends and bank Holidays as a base for picking up their medication on those specific days to reduce the amount of medication taken home. If you need any further Information please contact me at the above address. Yours sincere! ] afeg wa CLOCC TER OZOK<- 67:22 60-90-20
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