Prevention of Future Deaths reports · 2014
Regulation 28 report to prevent future deaths, reference 2014-0177, written 16 Apr 2014. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 16 Apr 2014 |
|---|---|
| Reference | 2014-0177 |
| Deceased | Kathryn Sawyer |
| Coroner | Jacqueline Lake |
| Coroner area | Norfolk |
| Category | Community health care and emergency services related deaths |
| Organisation named | Norfolk and Suffolk 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.
REGULATION 28: REPORT TO PREVENT FUTURE DEATHS (1) NOTE: This form is to be used after an inquest. REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: Roundwell Medical Centre 25-27 Dr Torrens Way Costessey Norwich NR5 0GB 1 | CORONER | am JACQUELINE LAKE, senior coroner, for the coroner area of Norfolk 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 15" August 2013 | commenced an investigation into the death of KATHRYN | LOUISE SAWYER, 33 years. The investigation concluded at the end of the inquest on 8™ APRIL 2014, The medical cause of death was Respiratory failure due to overdose of Methadone in combination with therapeutic levels of other drugs. The conclusion of the inquest was Accidental overdose of prescribed medication. 4 | CIRCUMSTANCES OF THE DEATH Mrs Sawyer had a significant history of mental health issues. She was prescribed Chioral Betaine in 2003. She was prescribed Methadone in 2011 following an addiction to Codeine. Mrs Sawyer was seen regularly at her GP surgery and by Mental Health Services. At the time of her death Mrs Sawyer was prescribed a number of different medications. Mrs Sawyer was very knowledgeable about medication and regularly requested increases. On 44" August 2013 Mrs Sawyer was found collapsed and unresponsive at the bottom of a flight of stairs in the communal hallway at her home address. She was found by a neighbour who called the ambulance service. Mrs Sawyer was transferred to Norfolk.& Norwich University Hospital where she died shortly after arrival. 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) Mrs Sawyer registered with the Roundwell Surgery in July 2012 at which time she was known to be addicted to Chioral Betaine (she was prescribed double the dosage recommended in the BNF) and was prescribed a number of different additional medications, including Methadone (prescribed by Trust Alcohol and Drug Service); , (2) She attended the Surgery with a letter from her previous GP expressing Mrs Sawyers’ concerns about her medication being decreased. It was felt sensible to allow her to feel comfortable with the Surgery before consideration was given to the Medication and amounts she was being prescribed. This is accepted as reasonable. -| (3) During the course of the next 13 months Mrs Sawyer was seen by the Practice on a regular basis when her medication was varied and/or increased. She was admitted to Hospital in November 2012 as a result of an overdose. (4) Mrs Sawyer’s mental health condition stabilised in Spring 2013 when she attended the Surgery for physical problems only. (5) Her medication was not reviewed by the Surgery until June 2013. It was then reviewed by a Locum Doctor. There is no or no detailed record of the discussion relating to her medication and no plan made between patient and the surgery with regard to future medication and in particular any plan to decrease. ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and | believe your organisation has the power to take such action. YOUR RESPONSE You are under a duly to tespond to this report within 56 days of the date of this report, namely by 11 June 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. | have sent a copy of my report to the Chief Coroner and to the following Interested Persons: Chief Executive Norfolk & Suffolk NHS Foundation Trust Hellesdon Hospital ; Drayton High Road Norwich NR6 5BE 1am 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 COPIES and PUBLICATION response, about the release or the publication of your response by the Chief Coroner. 46 April 2014 iN k
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.
Roundwell Medical Centre Jacqueline Lake 25-27 Dr Torrens Way Senior Coroner Costessey 69-75 Thorpe Road Norwich Norwich NR5 0GB Norfolk Tel: 01603 744014 NRi 1UA Fax: 01603 726549 Email: 2" June 2014 Dear Coroner Re: Katheryn Louise Sawyer Inquest Regulation 28 | refer to the Regulation 28 form issued to showing the inquest into the death of Katheryn Louise Sawyer, held on 8" April 2014. The circumstances around the death and the Regulation 28 form were discussed at our Clinical Governance meeting held on 24" April 2014. Six of the GPs were present together with members of the nurse team and the Practice Manager and Assistant Practice Manager. The following actions were agreed in order to prevent the circumstances around Mrs Sawyer’s death happening again within the practice. 1. For all patients on addictive medication will see only one GP, where possible, to provide for continuity of care for that patient. Action - immediate 2. For patients being put on addictive medication, the GP will ensure that the clinical plan / management is fully detailed in the patients’ medical records. Action — immediate 3. All patients who receive their medication weekly are to have a read code added to their medical record in order that they are easily identified, monitored and audited. Action — read code immediate, audit to be carried out within one month, 4. All patients on long term medication of Benzodiazepines and Opiates will have a six month medication review which will document the clinical plan/ management discussed with the patient.. Action — immediate 5. Patients referred to Norwich Recovery Partnership to have a read code added in order that they are easily identified, monitored and audited. Action — immediate 6. A bespoke “Addictive Medication Review” template to be designed to ensure that all reviews are documented and completed correctly. Action — within 3 months 7. All patients on weekly medication to be included in the risk profiling for the Unplanned Avoidable Admissions Directed Enhanced Service, which will be reviewed on a regular basis. Action — within 3 months 8. Where a patient is requesting a prescription for an addictive medication earlier than it is due, the administration team will add a note to the patient records and send an internal task to the relevant GP to consider appropriate action eg GP will contact patient and ask them to come to the surgery for a face to face appointment. Action ~ immediate 9. An audit to be completed on all patients being prescribed methadone. Action — within one month 10. All methadone maintenance medications need to be read coded and linked to a “problem” on the patients’ medical records. Any prescription added by an outside agency eg Norfolk Recovery Partnership, needs to be noted on patients records. Action — immediate 11.Concerns were noted for those patients on addictive medication who failed to attend appointments. Agreed a regular search would be completed to identify patients and relevant action to be taken. Action — regular monthly search. If you require any further information or some clarification on the actions noted above please do not hesitate to contact me. Yours sincerely Practice Manager For and on behalf of Roundwell Medical Centre
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