Prevention of Future Deaths reports · 2014
Regulation 28 report to prevent future deaths, reference 2014-0359, written 5 Aug 2014. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 5 Aug 2014 |
|---|---|
| Reference | 2014-0359 |
| Category | Alcohol, drug and medication related deaths |
| 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.
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. South West Ambulance Service 4 CORONER 1am Dr Elizabeth Ann Earland, HM Senior Coroner for the Exeter and Greater Devon District. 2 | CORONER’S LEGAL POWERS | make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and — 28 and 29 of the Coroners (Investigations) Regulations 2013. 3. | INVESTIGATION and INQUEST On 10" December 2012 | commenced an investigation into the death of Clare Louise BAIN, aged 40. The investigation concluded at the end of the Inquest on 1st August 2014. The conclusion of the inquest was ‘Drug Related Death’. On the evening of the 4" December 2012 the Deceased, who was prescribed Methadone and Valium, ingested a fatal quantity of prescribed and non-prescribed Methadone and Valium at 68 Millway Avenue, Axminster, after having been resuscitated at 00.24 hours 5" December 2012 with Naloxone with good effect she later succumbed. 4 | CIRCUMSTANCES OF THE DEATH Deceased on prescribed Methadone when on the evening of the 4" December 2014 she was found collapsed on a mattress on the floor at 68 Millway Avenue, Axminster, at 23.55 hours. South West Ambulance called and Mr Nicholas Clarke, Paramedic, arrived at 00.11 hours and diagnosed Methadone overdose. He administered Naloxone to good effect so much so that Deceased declined an offer to go to hospital and paramedics left her in care of neighbours until Husband returned at 04.00 hours. At 07.06 the Deceased had a cardiac arrest and South West Ambulance called, arrived at 08.05 to discover Deceased had apparently succumbed to effects of Methadone, Despite CPR by Husband and neighbour then paramedics with drugs of resuscitation it was too late and death pronounced at 08.43 5"' December 21012. Cause of death: Toxic effects of Methadone and Diazepam. 5 | CORONER’S CONCERNS During the course of the inquest the evidence revealed matters giving rise to concem. 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. — [BRIEF SUMMARY OF MATTERS OF CONCERN] (1) That given Deceased had declined to go to hospital the paramedics were under the impression that this was a heroin overdose and the use of one dose Naloxone was sufficient to counteract the effects of the opiate. (2) If paramedics are unaware that the respiratory depressive effects of Methadone last longer that the antagonism afforded by Naloxone there is a danger of further deaths because lack of repeat treatment doses of Naloxone when opiates are still active. ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and | believe you [AND/OR your organisation] have the power to take such action. (1) Review training of Paramedics in giving opiate antagonists (2) Consider a more robust protocol for dealing with respiratory depressant effects of opiates to include mandatory admission to hospital until the effects have passed and drugs metabolised. YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by [DATE]. 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. COPIES and PUBLICATION | have sent a copy of my report to the Chief Coroner and to the following Interested Persons [NAMES] [and to the LOCAL SAFEGUARDING BOARD (where the deceased was under 18)]. | have also sent it to [NAMED PERSON] who may find it useful or of interest. | 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. Dear Elizabeth A Earland MB.Ch.B., D.A.,Dip.Law,L.P.C,Hon.LLD HM Senior Coroner Room 226 County Hall th Topsham Road 5" August 2014 EXETER Devon EX2 4QD
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.
South Western Ambulance Service NH. j - NHS Foundation Trust RECEIV ED 2 9 SEP 2014 Trust Headquarters Abbey Court Eagle Way Exeter . - . Devon Private and Confidential EX2 7HY Dr Elizabeth A Earland HM Senior Coroner for the County of Devon ro Exeter and Greater Devon Coroner’s Office Website: www.swast.nhs.uk Room 226 Devon County Hall Topsham Road EXETER EX2 4QD Your reference: By recorded post and secure email: coroner@exgd-coroner.co.uk 26 September 2014 Dear Dr Earland, Clare Louise BAIN Deceased — DOD 05/10.2012 Inquest: 1 August 2014 at County Hall, Topsham Road, Exeter Coroner’s Rule 28 Report Thank you for your letter regarding the above inquest under Schedule 15 to the Coroners and Justice Act 2009 and Regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. | set out the Trust's response below: Recommended Action Your Regulation 28 Report recommends that we: 1) review the training of paramedics in giving opiate antagonists; and 2) consider a more robust protocol for dealing with respiratory depressant effects of opiates to include mandatory admission to hospital until the effects have passed and drugs metabolised. Response 1) Review training in relation to opiate antagonists On the 1* October, the Trust will be issuing further guidance for clinicians to raise awareness of methadone overdose and how it should be treated. The guideline will highlight: . ¢ the particular characteristics of methadone including the extent to which it acts slowly, meaning that overdose can initially be asymptomatic, and its potential to stay in the system for a long time. e the difference in the elimination half life of methadone (15-40 hours) and naloxone (1-1.5 hours) and the need to convey the patient to hospital for further observation, even where they have responded well to initial treatment. ¢ Action to take if a patient refuses to be transported to hospital. | have enclosed a copy of the Clinical Notice in its current draft form for your information with a final version to follow by the end of October 2014. 2) Consider a more robust protocol for dealing with respiratory depressant effects of opiates to include mandatory admission to hospital. Our aim in releasing the methadone overdose Clinical Notice is to ensure that all our clinicians are fully aware of the most appropriate treatment options for methadone overdose. This includes the importance of transporting the patient to hospital. Particular issues arise in respect of methadone overdose patients who refuse to be conveyed to hospital, despite the risks being fully explained and emphasised to them. It is our experience that, because they do not feel unwell, some patients who have taken an overdose do not accept that they require close monitoring in hospital or that they are likely to need further treatment. As you will be aware, our clinicians can only transport a patient to hospital without his/her consent if he/she is assessed as lacking capacity to make their own decision regarding their medical treatment under the provisions of the Mental Capacity Act 2007. However, in methadone overdose cases, a patient who does not feel unwell will often have sufficient capacity and awareness to make decisions regarding their treatment. To assist clinicians in the effective and robust assessment of patient capacity we have recently issued a new and detailed mental health guideline, which provides clear and detailed guidance regarding capacity assessments. | have enclosed a copy for your reference. In addition, the Trust has now started to trial an electronic patient record system which will be rolled out more widely going forward. The system has been configured to allow clinicians to run through a structured assessment which complies with the Mental Capacity Act and best practice guidelines. The methadone overdose Clinical Notice sets out the steps clinicians should take in respect of a methadone overdose patient with capacity who refuses transport to hospital including: e Ensuring that the patient is left with a responsible adult who can monitor the patient over the next 8 hours; ¢ Giving comprehensive and well-documented advice on steps to take if the patient's condition worsens; ¢ Notifying the Clinical Supervisors in the Trust’s control centre that the situation may deteriorate rapidly and notifying other out of hours service providers as appropriate. More generally, the Trust is also working with other agencies to address some of the particular challenges that methadone overdose presents. Our Accountable Officer, along with one of our senior clinicians, presented a similar case study at the Controlled Drug Local Intelligence Network (Bristol, North Somerset and South Gloucestershire) Annual Learning Meeting in July this year. This meeting is attended by the Police and other healthcare agencies including those concerned with substance misuse and harm reduction. The Police commented that even if they transported the patient to hospital, there was currently not a mechanism to detain the patient against their wishes. A consultation has been carried out by the Medicines and Healthcare Products Regulatory Agency regarding their proposal to allow wider access to naloxone for use in emergencies. (https://www.gov.uk/government/consultations/proposal-to-allow-wider-access-to- naloxone-for-use-in-emergencies). Supplying naloxone to clients receiving methadone, and providing both them and their friends and family with appropriate education and training, could lead to the provision of an additional safeguard in the future. | hope the information contained within this letter provides you with assurance that the Trust is committed to reviewing its own practices and working alongside our colleagues in the wider health community to provide effective care to methadone overdose patients. If | can provide any further information, please do not hesitate to contact me. Yours sincerely, Deputy Clinical Director Enc: Draft clinical notice: Management of Oral Methadone Overdose Clinical guideline: Mental Health and Mental Capacity Chairman: Heather Strawbridge ee Chief Executive: Ken Wenman Sign up hitpsy/secure membra.co.uk/swambapplicationforn to be a member
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