Prevention of Future Deaths reports · 2014
Regulation 28 report to prevent future deaths, reference 2014-0224, written 12 May 2014. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 12 May 2014 |
|---|---|
| Reference | 2014-0224 |
| Deceased | Courtney Mills |
| Coroner | David Horsley |
| Coroner area | Portsmouth & South East Hampshire |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| Organisation named | Portsmouth Hospitals University NHS Trust |
| Source | judiciary.uk record · original PDF |
| Responses published | 2 |
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.
ANNEX A 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: 1. The Chief Executive, Portsmouth Hospitals NHS Trust 2. The Practice Manager, Waterside Medical Centre, Mumby Road, Gosport, PO12 1BA 1 | CORONER | am David Clark Horsley, senior coroner for the coroner area of Portsmouth and South East Hampshire. 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 Ons" May 2013 | commenced an investigation into the death of Courtney Jordan Mills, aged 11 years. The investigation concluded at the end of the inquest on 24" March 2014. The conclusion of the inquest was Medical Cause of Death: Acute Bronchopneumonia in a child with Sleep Apnoea and Cerebral Palsy. Coroner's Conclusion as to the death: Death due to Natural Causes. 4 | CIRCUMSTANCES OF THE DEATH Courtney was found unresponsive in bed at her home on 19" April 2013. She was taken to Queen Alexandra Hospital, Portsmouth where she was pronounced deceased at 09.45 hours that day. 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. — | was told that (quote): "Courtney was on a quantity of different medication for her conditions one of which is “Clonodine”. Her parents reported that they had been having problems getting the correct prescriptions for this from the GP surgery (written as tablets instead of solution, wrong dosage etc) and this caused problems. This drug cannot just be stopped as the patient suffers from withdrawal symptoms and has to be weaned off gradually. The drug was ordered in by the Pharmacist and could take 5 days to get in so the prescription was always requested in advance of when it was required. Courtney's supply was running low and a prescription was collected by mother and taken to the pharmacy. She returned a few days later she was told that the prescription had been written wrongly and had been returned to the GP and she should have been called by them. Neither parent had received a call. Mother attended the surgery and was told that the prescription could not be done until they had spoken to Courtney's consultant at SCH aa or they would be called when done. No calls received. Courtney's last dose of this medication was due to be given on Thursday morning and father continued to contact the GP surgery on Wednesday but was told it was not ready, he called again on Thursday to an answering machine stating the practice was closed for a training day. He was due to go into the surgery this morning to discuss the matter with the GPs." | was also told that Clonodine could be obtained from the pharmacy at Queen Alexandra Hospital for patients under the care of a consultant - as was Courtney. There had been a history of delay in her obtaining this medication due to communication difficulties between the hospital and her GP surgery. | believe such a problem could put other children's lives at risk in similar circumstances. 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 duty to respond to this report within 56 days of the date of this report, namely by 7" July 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, to Courtney's parents and to the LOCAL SAFEGUARDING BOARD (where the deceased was under 18). | 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 publicatio sponse by the Chief Coroner. 12™ May 2014
2 responses 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.
Portsmouth Hospitals INHS NHS Trust Trust Headquarters F Level, Queen Alexandra Hospital Ursula Ward MSc MA Southwick Hill Road Chief Executive Cosham PORTSMOUTH, PO6 3LY PRIVATE & CONFIDENTIAL 23 June 2014 Mr D C Horsley Senior Coroner for Portsmouth & South East Hampshire Coroner's Office Room T20 The Guildhall Guildhall Square Portsmouth PO1 2AB Our ref: UW/SS/Q67/13 (Please quote our ref in all correspondence) Dear Mr Horsley Courtney Jordan Mills — 1063/13 (DOB 12/06/2002 - DOD 19/04/2013 | refer to your letter with which you enclosed a Regulation 28 Report dated 12 May 2014. | note that this report was also sent to the Practice Manager of the Waterside Medical Centre in Gosport. As you will of course recall nn Consultant Paediatrician, gave evidence at the Inquest and | have therefore sought his input into this response as well as from our Pharmacy Department. The report states that there had been a history of delay in Courtney obtaining her medication (Clonidine) due to communication difficulties between the hospital and the GP surgery and you have asked that action be taken to prevent future deaths. | understand from | that the Clonidine was not in fact prescribed by Portsmouth Hospitals NHS Trust and our Pharmacy Department have also confirmed that we have no evidence to suggest that Queen Alexandra Hospital were approached for a supply of the drug, although had we been approached, we would have supplied it. In past situations like these, where community pharmacists have had trouble getting hold of non-routine medicines, the patient's family have contacted our Children’s Assessment Unit (CAU) who have arranged for it to be prescribed by a doctor here and then we have dispensed it from the QAH pharmacy. This is a situation that we are used to and we would have done this in this case. However, had CAU been asked, they may have had a problem verifying the usual dosage, in which case we would have had to contact Southampton prior to writing the prescription. - 2- | am aware that maintaining correct medication when patients leave hospital is a significant problem across the NHS as it involves co-ordination between hospitals, GP practices, pharmacy and patients themselves, often with an important medication change made as a result of acute illness. While doctors clearly share responsibility for this, Pharmacists may be best placed to ensure safe processes around this. In the first instance, and if you feel that this issue needs to be considered on a national level, | would suggest that the Royal Pharmaceutical Society may be the best body to contact. In the circumstances, | should be grateful if you could confirm that this response is sufficient and that you do not require Portsmouth Hospitals NHS Trust to take any further steps in respect of your report. With best wishes Yours sincerely Ursula Ward MSc MA Chief Executive
WATERSIDE MEDICAL CENTRE Mumby Road Gosport PO12 1BA “eres | www.watersidemedicalcentre.nhs.uk RECEIVED 27 JUN 2014 BY H.M CORONER Our ref: CB/mlo 23rd June 2014 Mr David Horsley Senior Coroner for Portsmouth and SE Hants Coroner’s Office Room T20 The Guildhall Guildhall Square PORTSMOUTH PO1 2AB Dear Mr Horsley Re: Miss Courtney Mills, DoB 12/06/2002 42 Forton Road, Gosport, Hants, PO12 4TH We received your letter on 13.5.2014 regarding a Regulation 28 Report on Courtney Jordan Mills. An inquest had been held on 24.3,2014 into the death of Courtney Mills and | believe that copies of computer records of Courtney’s GP notes were sent to you on 28.10.2013. Courtney's registered GP wos who attended the j t that time provided information about matters of concern listed on Section 5 of Regulation 28] has now left the Practice and is currently having a year of adoption leave. My involvement was as follows: Friday 15" March 2013: | received a telephone call from the pharmacist regarding a prescription for Clonidine tablets which had been issued two days earlier b P| notes from the 13™ March when she was doing that prescription state, “Medication requested. New meds from hospital so script done”. | assume from this tha 3 done the prescription based on the hospital’s recommendation although | cannot find a hospital discharge letter from that time in Courtney’s notes. The pharmacist was querying the prescription as Courtney had been on Clonidine liquid in hospital and mum had told her that Courtney could not swallow Clonidine tablets. The pharmacist was concerned as she was unable to get Clonidine liquid immediately as it is available only as a special order and would take five days or So to arrive. Courtney had completely run out of her Clonidine liquid and it was Friday afternoon, so the options were very limited. | rang the paediatrician on call at Southampton General Hospital, as had come into the surgery late on Friday afternoon to try and resolve this. The paediatrician on call discussed Courtney with Courtney's consultant at Southampton General and they decided that it was not ideal to crush the tablets, and they suggested instead increasing her Chloral Hydrate solution instead of having the Clonidine. They were due to see Courtney on the following Monday so they planned to give Clonidine liquid from the hospital pharmacy at that appointment. They also suggested that could go across to Southampton to get a new supply from them straightaway but she was unable to get to Southampton to do this. | was next involved on the 12" April 2013 — also a Friday. | had come to the surgery that afternoon, again needing a prescription of Clonidine solution. Mum said that she had a new discharge letter from Southampton Hospital which she had not yet dropped into the surgery but she said that it instructed that Courtney should take an increased dose of Clonidine solution. At that point EEE told me that they had enough Clonidine solution to last for another week and when we” contacted the pharmacy they again said that it would take at least a week to get this medication. At that time mum said she would ask at the hospital appointment at the end of the month whether any sort of patches could be used instead of Clonidine solution. | supplied a handwritten prescription for a thirty days supply of Clonidine oral solution. This product is not available on the computer formulary as it is a special order and has to be specially ordered in by the pharmacy. Because of the difficulties in obtaining Clonidine solution ED wrote ro the consultant paediatric neurologist in Southampton, on 15.04.2013 to ask for some clarification about the medication, and to explain the difficulties we were having obtaining the medication in the community. BR then spoke to on one on 18.04.2013 regarding the Clonidine prescription. They discussed the transdermal option but felt there were medico-legal issues as it was off licence. felt that it was more appropriate that Southampton carried on supplying the medication and explained the difficulties tol these being that there was a week’s delay, minimum, in sourcing Clonidine solution in the community and it was also impossible to issue it via the computer. P| said that she would discuss the matter further with the hospital pharmacy. I can completely understand how frustrating this has been. It may not have been obvious how much hard work had gone on behind the scenes to try and obtain and find an answer to the problem of getting Clonidine solution. It was always readily available at Southampton hospital pharmacy but was never easily available in the community. | would respectfully suggest that the delay in obtaining the medication was not due to communication difficulties between ourselves and the hospital. | believe that it was because the medication simply was not available in the community except with a week’s notice to the pharmacy. The GP’s at Waterside Surgery have spent some considerable time trying to sort this out with the pharmacies and with Southampton. We have clearly documented in Courtney's notes the many occasions on which this has happened. Yours sincerely
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