Prevention of Future Deaths reports · 2014
Regulation 28 report to prevent future deaths, reference 2014-0341, written 25 Jul 2014. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 25 Jul 2014 |
|---|---|
| Reference | 2014-0341 |
| Deceased | Donna Kirkland |
| Coroner | Jason Pegg |
| Coroner area | Coventry |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 2 |
Text extracted from the PDF text layer. 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.
1
REGULATION 28 REPORT TO PREVENT FUTURE DEATHS
THIS REPORT IS BEING SENT TO:
1.The Rt Hon Jeremy Hunt MP, Secretary of State for Health Department of Health, Richmond House, 79, Whitehall, London, SW1A 2NS 2.Coventry & Warwickshire Partnership Trust Wayside House, Wilsons Lane, Coventry, CV6 6NY1CORONER
I am Jason Pegg, Assistant Coroner, for the coroner area of Coventry & Warwickshire. 2CORONER’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. 3INVESTIGATION and INQUEST
On 21st July 2014 I commenced an investigation into the death of Donna Kirkland, aged 30 years. The investigation concluded at the end of the inquest on 24th July 2014. The medical cause of death was, "Ingestion of alcohol and venlafaxine". A narrative conclusion was given by the jury, in summary, "The source of the alcohol was the alco-gel (hand sanitiser) found in the ward area and accessible to patients. The alco-gel was consumed in her room, room 1, Beechwood Ward, Caludon Centre, Coventry." 4CIRCUMSTANCES OF THE DEATH
Donna Kirkland was admitted to the Beechwood Ward, Caludon Centre, Coventry on 30th July 2013. On 19th August 2013 Donna was detained on the ward under the provisions of section 2, Mental Health Act, 1983. Donna was prescribed appropriate medication for her condition, one such drug was venlafaxine, prescribed at appropriate therapeutic dosage. On 22nd August 2013, at 0730 hours, Donna was found deceased in her bed on the Beechwood Ward. A 500 ml Lucozade bottle was found beside her bed which contained 250 ml of liquid containing alcohol (ethanol and isopropyl alcohol). The alcohol content was 66% weight per volume. The alcohol liquid was clear and of gel like consistency. The liquid was an alcohol based hand sanitising gel ("Purell" manufactured by Gojo) which was readily accessible to patients from a dispenser installed close to the main doors of the ward. Patients were not only allowed to access the dispenser but were permitted, if they so wished, to fill cups or other containers with the alcohol based hand sanitising gel. Patients were allowed to keep alcohol based hand sanitising gel in their rooms. A polystyrene cup containing 1 cm of alcohol based hand sanitising gel was found on Donna's bed on the morning of 22nd August 2013. 214 mg of alcohol in 100 ml of blood was found in Donna's post-mortem blood sample. A combination of the alcohol and venlafaxine had caused Donna's breathing to be suppressed resulting in her death.
!
2
5CORONER’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)Patients having unlimited access to alcohol based hand sanitising gels; (2)Patients being permitted to decant alcohol based hand sanitising gels into cups and other such containers; (3)Patients being permitted to keep cups and containers of alcohol based hand sanitising gels in their rooms; (4)Lack of awareness amongst staff of alcohol content of alcohol based hand sanitising gels and the potential for such gels to be ingested. 6ACTION SHOULD BE TAKEN
In my opinion action should be taken to prevent future deaths and I believe you or your organisation have the power to take such action. 7YOUR RESPONSE
You are under a duty to respond to this report within 56 days of the date of this report, namely by 19th September 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. 8COPIES and PUBLICATION
I have sent a copy of my report to HHJ Peter Thornton QC, Chief Coroner 11th Floor, Thomas More Building, Royal Courts of Justice, London, WC2A and to the following Interested Persons: 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. 925th July 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.
From Dr Dan Poulter MP Parliamentary Under Secretary of State for Health Departm ent Richmond House of H e alt h 79 Whitehall London SW1A 2NS POC5 879159 Tel: 020 7210 4850 Mr Jason Pegg HM Assistant Coroner for Coventry and Warwickshire 22 SEP 2014 The Coroner's Office Central Police Station Little Park Street Coventry CV1 2JX Deus wv He, Thank you for your letter to Jeremy Hunt about the death of Donna Kirkland. | am responding on his behalf as the Minister with responsibility for patient safety. Ms Kirkland was found dead in her bed having drunk an alcohol based sanitising gel. A Lucozade bottle containing 250ml of alcohol based hand sanitising gel was found beside her bed. It was determined there was a reaction between the gel and a drug Ms Kirkland had been prescribed for her condition (venlafaxine). However the level of alcohol in Ms Kirkland’s blood was very high and this too would have been a risk to health even had she not been on that particular medication. Your report explains the circumstances around Ms Kirkland’s death and concludes that the medical cause of death ‘ingestion of alcohol and venlafaxine’. You had a number of concerns about this case, including the following, o Patients having unlimited access to alcohol based hand sanitising gels o Patents being permitted to decant alcohol based hand sanitising gels into cups and other containers o Patents being permitted to permitted to keep cups and containers of alcohol based hand sanitising gels in their rooms o Lack of awareness amongst staff of the alcohol content of alcohol based hand sanitising gels and the potential for such gels to be ingested. | was concerned to learn that at the time of Ms Kirkland’s death the Caludon Centre allowed patients to collect and store an alcohol-based solution of this kind, with the obvious potential for abuse. | know that the Care Quality Commission has inspected the Caludon Centre twice this year and has required immediate improvements. National guidance is already in place in ‘Preventing Suicide- A Toolkit for Mental Health Services’, which can be found at http://www. nrls.npsa.nhs.uk/resources/?entryid45=65297&q=0%c2%acsuicide%c2%ac . In addition, individual and environmental risk assessments should always be completed, evaluating whether the risk associated with hand-sanitizer gel is being managed in particular relation to each person’s presenting profile of need. There is further national guidance detailed in ‘Preventing Suicide in England- a cross- government outcomes strategy to saves lives, (Sept 2012). This strategy helps identify high risk groups such as those with both alcohol related and mental health issues. The strategy document can be found at https://www.qov.uk/government/uploads/system/uploads/attachment_data/file/216928/Prev enting-Suicide-in-England-A-cross-government-outcomes-strategy-to-save-lives.pdf and is also attached for your convenience. | would expect that the local Post Suicide Review would examine documented local measures of assessing and managing these additional risks and what learning can be gleaned to respond and manage such incidents in the future. In reviewing medication safety incidents from the NRLS, there have been relatively few incidents of ingestion of this sort. These types of incidents may however be reported to the NRLS under headings other than ‘medication incidents’ and further work would need to be done to identify these. Although incidents of this nature have been reported nationally, the number has significantly reduced as a result of local risk mitigation measures as described in the guidance above. However, there will of course be continued national oversight of reports and learning from such incidents. | hope that this information is helpful and | thank you for bringing the circumstances of Ms Kirkland’s death to our attention. Bot LU, DR DAN POULTER
FAO Mr J Pegg
Assistant Coroner
The Coroner’s Office
Civic Centre 1,
Little Park Street,
Coventry,
CV1 5RS
18th September 2014
Dear Sir
Re: Donna Louise Bernadette Kirkland (deceased)
Thank you for your letter of 28 July 2014 enclosing the regulation 28: Report to Prevent
Future Deaths in this matter.
We welcome the Coroner’s interest and concern in ensuring future deaths are prevented
and that any risks to patients around alcohol-based hand sanitising gel (alcogel) are
minimised.
The Trust also shares your wish to bring the potential risks of alcogel to the Secretary of
State, and is grateful to have been provided with a copy of the report that you have
produced. It is not our understanding that you have sent the report to the
Trust because you have identified that we need to do more than has already been done to
further reduce the risk associated with alcogel. However, if we have misunderstood the
purpose of you naming the Trust in the report, we would be grateful for clarification,
particularly if there are further steps you believe the Trust should be taking.
Alcogel is a key part of infection control measures, both at the Coventry and Warwickshire
Partnership NHS Trust and nationwide in both NHS and private hospitals. An alcohol-free
alternative has recently become available to NHS institutions. It does have some
drawbacks compared to alcogel. Nevertheless, prior to the hearing of the inquest this
summer, the Trust had investigated for itself this alternative, and had decided to replace the
wall-mounted alcogel dispensers on its premises with this alcohol-free alternative.
At the inquest the questions of access to, and use of, alcogel were explored with a number
of witnesses from the Trust. Evidence was heard at the inquest, and accepted by the
Coroner, that following Donna’s death the Trust had taken steps proactively to review the
access to and use of alcogel across inpatient units and to raise the awareness of its staff of
- Chair
– Chief Executive
Coventry & Warwickshire Partnership NHS Trust
Wayside House, Wilsons Lane, Coventry, CV6 6NY
Tel: 024 7636 2100 Fax: 024 7636 8949
www.covwarkpt.nhs.uk
in partnership with:
the potential risks associated with the ingestion of alcohol. The Coroner was informed that
the Trust was already in the process of replacing wall-mounted alcogel dispenser with the
alcohol-free alternative. This process has now been completed.
The inquest did not identify any further steps which Coventry and Warwickshire Partnership
NHS Trust might take to reduce the risk of future deaths.
The Trust will continue to monitor access to and use of alcogel across its sites.
The Trust endorses the Coroner’s wider concerns and would be happy to speak to the
Department of Health if they would like more information on the lessons learned and the
changes that have been made within the Trust.
Yours sincerely
Chief Executive
- Chair
– Chief Executive
Coventry & Warwickshire Partnership NHS Trust
Wayside House, Wilsons Lane, Coventry, CV6 6NY
Tel: 024 7636 2100 Fax: 024 7636 8949
www.covwarkpt.nhs.uk
in partnership with:
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