Prevention of Future Deaths reports · 2014
Regulation 28 report to prevent future deaths, reference 2014-0517, written 26 Nov 2014. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 26 Nov 2014 |
|---|---|
| Reference | 2014-0517 |
| Deceased | Anthony Huggan |
| Coroner | Lisa Hashmi |
| Coroner area | Manchester North |
| Category | Other 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.
REGULATION 28: REPORT TO PREVENT FUTURE DEATHS (1) REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: 4. The Chief Executive, Bury Metropolitan Borough Council CORONER lam Ms L J Hashmi, Area Coroner for the Coroner area of Manchester North CORONER’S LEGAL POWERS | make this report under paragraph 7, Schedule 5, of the Coroner’s and Justice Act 2009 and Regulations 28 and 29 of the Coroners (Investigations) Regulations 2013 INVESTIGATION and INQUEST On the 10” June 2014 | commenced an investigation into the death of Anthony Maurice Huggan CIRCUMSTANCES OF DEATH Mr Huggan had a long standing drug problem. Having served a short sentence of imprisonment, he was released from custody on the 2"? June 2014. The same day, he took an accidental overdose of opiates resulting in his admission to hospital. At the point of admission, he was gravely ill. Urgent medical treatment was initiated and he was admitted to HDU with a Naloxone infusion. On the 3 June 2014 the deceased decided to take self-discharge, against medical advice. He was assessed and deemed to have mental capacity to make that decision. He was advised of the potentially very serious consequences (including death) but nonetheless took self-discharge. A telephone call was made (it is believed by the hospital’s Pharmacist) to the community drugs team to advise them of Mr Huggan’s actions, so as to ensure safe follow up in the community. Post discharge, Mr Huggan took excessive amounts of prescribed and illicit substances. The voicemail message relating to the deceased’s self-discharge was picked up from the CDT answerphone on the 4" June 2014. The housing support officers attended the deceased’s address the same day and were met by his friend who was concerned about Mr Huggan’s health (he had been up most of the night checking upon him). Mr Huggan was subsequently found deceased in bed. Post mortem examination and toxicological analysis showed that the deceased died as a result of combined drugs toxicity (Pregablin, Morphine and Methadone). During the course of the evidence, it transpired that the Community Drugs Team are commissioned to provide care to service users between the hours of 09:00-17:00, Monday to Friday. There is no ‘out of hours’ provision. In the event of an emergency, service users are told to contact A & E, their GP or the Police. 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:- 4. The lack of a suitable out of hours service, resulting in an undue burden being placed upon the emergency services and the NHS (none of whom are best placed to deal with and support those with drug addiction problems). . 2. Where a patient takes self-discharge following a life threatening drugs overdose, concerns arise around the timeliness of follow up/welfare checks, given the limitations of the service commissioned by the Local Authority. ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and | believe each of you respectively 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 21° January 2015, 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 namely:- - Family of the deceased - Legal representatives of the acute Trust - CDT Bury lam 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 from. 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. Date: De . \k ZO. signed LR
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.
Executive DirectorofCommunities & Wellbeing COUNCIL Our Ref U/klc Your Ref LIHIGI/53642-2014 Date Please ask for Direct Line Assistant Director (Operations) E-mail Greater Manchester North HM Coroner’s Court The Phoenix Centre MC Way Heywood Rochdale OL1O 1LR For the attention of Mrs Lisa Hashmi, Area Coroner Dear Mrs Hashmi INQUEST TOUCHING THE DEATH OF ANTHONY MAURICE HUGGAN, DECEASED We write further to your letter of 27 November 2014 regarding the above named person (deceased) and your request for a response to matters of concern raised in your Report to Prevent Future Deaths (Regulation 28). Before responding to the matters of concern you raise, we would like to provide some contextual information in relation to commissioned substance misuse services in Bury. Following a competitive retendering process One Recovery Bury (ORB) were successful in securing the contract to provide a recovery orientated substance misuse service for adults in Bury. The contract start date was 1 February 2014 and the new model was implemented from 1 April 2014 (following TUPE of staff from the existing service). One Recovery Bury is a collaboration of Addictions Dependency Solutions (ADS), Sodexo Justice Services, Harvey House Social Enterprises and Bury Education Support and Training (Bury EST). The service is commissioned to provide flexible opening hours, including weekend and evening provision, which are responsive to local need. The service is also commissioned to provide satellite services, the operating hours of which are to be based on an assessment of local need. Work is currently ongoing to develop the flexible service in Bury, with plans to be put in place early in 2015. ADS is the lead provider of the consortium. ADS has in place a robust Serious Untoward Incident (SUI) policy and all SUI5 are thoroughly reviewed, actions noted. Operational responsibility for implementation of the action plans rests with the Service Delivery Director through operational service management structures. We do not accept 1st Floor, Town Hall, 4r . INVESTORS electronic or Knowsley Street, 4, ‘ IN PEOPLE fax service of legal Bury BL9 OSW documents www.bury.gov.uk I Bury Prestwjch Radcliffe Ramsbottom I Tottington Whitefield Each SUI review is chaired by the Chief Executive Officer of ADS who then reports to the Board of Trustees. Full organisational governance of SUIs rests with the ADS Board of Trustees through the Board led Professional Committee, the Chair of which is a former CQC inspector, and senior local authority social services manager of mental health services. In direct response to matters of concern; 1. Lack of suitable out of hours service resulting in an undue burden being placed on emergency services and the NHS (none of whom are best placed to deal with and support those with drug addiction problems). ADS has for some considerable number of years provided a 24/7 helpline service for criminal justice clients who are taken into custody ‘out of hours’ as these service users were subject to the Drug Intervention Programme (DIP) and this was a requirement of the commissioned service. However, this arrangement is now being reviewed because most ‘new’ services are integrated and prefer a system of on call and cover arrangements to be more localised and based on demand. These arrangements are to be planned and delivered on a local basis and will include cover arrangements for periods of maximum disruption to the service such as Christmas/New year and bank holidays and also includes senior management cover on a Director rota which applies 52 weeks a year. Consideration of Bury’s needs in relation to 24/7 helpline service will be considered early in 2015. In relation to an undue burden being placed upon the emergency services and the NHS, One Recovery Bury is not commissioned as an emergency service: it is commissioned as a recovery orientated treatment services and is resourced and staffed on that basis. However, as part of overdose prevention and education all service users are informed to dial 999 in emergencies such as suspected overdose or other medical emergency. Currently, if a call is made to the service out of hours, callers are given details of opening times and then advised “in the event of a medical emergency please dial 999”. Bury Council has in operation an Emergency Duty Team which is available out of hours (from 16:45 to 08:45; weekends and bank holidays). The service operates a single point of entry and all calls to the service are recorded. Call records for June indicate that no call was received in relation to Mr Huggan. 2. Where the patient takes self-discharge following a life threatening drugs overdose, concerns arise around the timeliness of follow up/welfare checks, given the limitations of the service commissioned by the local authority. Where a patient takes self-discharge following a life threatening drug overdose. One Recovery Bury would arrange to see the client at the earliest opportunity upon receiving the information concerning discharge (currently, One Recovery Bury does not always receive this information). We aim to see all clients leaving hospital within seven days (as per seven day follow-up). Any client leaving hospital is vulnerable to over dose, as are prison releases, particularly those who may have had a long hospital stay, had medication changes or have refrained from illicit drug use during their hospital stay. Yours sincerely ASSISTANT DIRECTOR, OPERATIONS
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