Prevention of Future Deaths reports · 2014
Regulation 28 report to prevent future deaths, reference 2014-0466, written 27 Oct 2014. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 27 Oct 2014 |
|---|---|
| Reference | 2014-0466 |
| Deceased | Philip Allen |
| Coroner | Philip Barlow |
| Coroner area | London Inner (South) |
| Category | Community health care and emergency services 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, BE <cnicr partner, Eltham Palace Surgery, 20 Court Yard, Eltham, SE9 5QA, 1 | CORONER | am Philip Barlow, assistant coroner, for the coroner area of Inner London South. 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 16 October 2012 | commenced an investigation into the death of Philip Allen. The investigation concluded at the end of the inquest on 20 October 2014. The conclusion of the inquest was that he died of natural causes. The medical cause of death was vascular dementia. 4 | CIRCUMSTANCES OF THE DEATH Philip Allen was diagnosed with vascular dementia in 2009. In September 2012 following a deterioration in his condition he was transferred from The Oaks Care Centre to QEH where he died. Mr Allen was admitted to The Oaks on or around 6 June 2012. He was seen by at that time a partner at Eltham Palace Surgery, who prescribed Quetiapine in addition to the Respiridone that Mr Allen was already taking. On 20 June 2012 Mr Allen was seen Os > consultant in old age psychiatry at Oxleas NHS Trust discontinued the Quetiapine and wrote to Eltham Palace Surgery accordingly. Despite this letter it appears that the Quetiapine continued to be prescribed to Mr Allen as a repeat prescription by Eltham Palace Surgery until September 2012. In evidence at the inquest [EE who has now retired from practice, stated that the matter had been investigated at Eltham Palace Surgery as an untoward incident but he was unable to give details of this investigation. 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. — as Mr Allen’s GP, sought specialist advi ‘om || Not only was this advice not followed but the Quetiapine, which had stopped, continued to be prescribed as a repeat prescription on several occasions. The evidence at the inquest was that the further prescriptions of Quetiapine did not contribute to the death. However, | am concerned that the system at Eltham Palace Surgery did not prevent the repeat prescription. Was unable to say if changes have been made since this incident. ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and | believe you as senior partner of Eltham palace Surgery have 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 23 December 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 following Interested Persons: 1. Aston Brooke Solicitors, acting for Mr Allen's family. 2, Weightmans LLP, solicitors acting for Priory Group which operates The Oaks Care Centre. | 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. 27 October 2014 Poet L/e Philip Barlow
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.
ELTHAM PALACE SURGERY 28 COURT YARD ELTj 95QA Te: lial Fax NO: EP/jw Dr Phillip Barlow Assistant Coroner Southwark Crown Court 1 Tennis Street London SE1 1YD 06 January 2015 Dear Dr Barlow, Philip Allen DOB. i] Tam sorry for the delay in responding to your letter regarding the above named gentleman. I was t directly involved with this gentleman’s care but from reviewing his computer notes I have identified the following: 1, I received a call on the 7 September 2012 from the nursing manager at the time, | She advised me that had apparently stopped his Quietiapine on the 19 June 2012 but that for event as there was no record/notification to the surgery that it had been discontinued, and to let me know the outcome of her investigation. 2, GE vr eviewed Mr Allen on the 20 June 2012. The letter to a ...; dated 3 July 2012. The letter was not sent to us and were only received by the practice on the 25 11 2014, when I started to make inquiries into the case. There is no record that any clinician or member of staff at the practice was informed about the change in medication. Unfortunately, I am yet to receive the nursing notes or Paper notes which may have an entry related to the alteration of medication for Mr Allen. Questions to ask. a. Was SS informed of the change and this was not actioned? b. Had the carers at the time also failed to inform Eltham Palace Surgery? ¢._ Why was the letter from HB never sent/received by the practice? As a practice we have made several changes to our policy in dealing with the care of clients at the Oaks Nursing Home:- Twice weekly ward rounds are conducted by myself and Medication reviews are done every 3 months by our Prescribing Advisor GE who is head of Medicines Management at the CCG. Medication reviews are done twice a year by the attending clinician at the practice were we have the ability to update the computer records which can then be translated into electronic Prescriptions which are sent directly to the pharmacist. No handwritten prescriptions are done at the home any longer and this is to ensure a proper audit trail of all prescribed medication. We have continually asked for an N3 line to be installed at the home so that we have direct access to up to date computer records concerning patients at the home. At the moment we have to hand write the ME notes which have to be photocopied and then translated into the computer records when the attending clinician returns to the practice. We have bought laptops which allow us to access some records but we are unable to access all our request forms and referral letters using this method. It is also time consuming and doubles our workload as all notes have to be made twice as the staff at the home have no access to patients computer records.
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