Prevention of Future Deaths reports · 2014
Regulation 28 report to prevent future deaths, reference 2014-0518, written 27 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 | 27 Nov 2014 |
|---|---|
| Reference | 2014-0518 |
| Deceased | David Greenfield |
| Coroner | Andrew Tweddle |
| Coroner area | County Durham & Darlington |
| Category | Hospital Death (Clinical Procedures and medical management) 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 THIS REPORT IS BEING SENT TO: 1. The Priory Group Ltd. Priory House, Randalls Way, Leatherhead, Surrey KT22 7TP CORONER | am Andrew Tweddle, senior coroner, for the coroner area of County Durham and Darlington 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. (see attached sheet) INVESTIGATION and INQUEST On 9/4/2014 | commenced an investigation into the death of David Peter Greenfield, aged 29 years. The investigation concluded at the end of the inquest on 26" November 2014. The conclusion of the inquest was “The deceased died unexpectedly as a result of his pre-existing natural heart disease combined with respiratory depression linked to obesity and the effects of the ingestion of drugs”. CIRCUMSTANCES OF THE DEATH The deceased at the time of his death was aged 29 years. He was obese and weighed 195 kilograms. He had abused alcohol and drugs for some years and had been prescribed methadone at a high daily dosage for a number of years. He was admitted to the Priory Hospital , Aspen Unit, Middleton St George at 12.30 p.m. on Wednesday 2% April 2014. He was assessed as a high risk patient and was subject to four observations per hour. He self admitted to the hospital to take part in an alcohol detoxification programme where no variation to his daily methadone intake was planned. There was confusion as to the amount of methadone the deceased had taken prior to admission and what he was to take and when on his first day of admission. In the event it would appear that the deceased took less methadone than he had been prescribed. He was prescribed Chlordiazepoxide as part of his alcohol detoxification process. He was breathalysed on admission and on subsequent occasions during his stay. No drugs screen was undertaken. The deceased was found unresponsive in his bedroom at 04.45 hours on the 3™ of April, i.e. less than 24 hours after admission. At post mortem it was found that he had ischaemic heart disease and that together with respiratory depression caused by drugs and his obesity led to his death. 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. — 1. Not everyone involved in his care was experienced in dealing with patients who had both drug and alcohol problems and the risks of respiratory depression in patients such as the deceased were not fully appreciated. The internal enquiry undertaken by The Priory following the deceased's death took into account experience and opinions of people within the organisation but did not draw upon research undertaken outwith the organisation on the question of sudden and unexpected deaths of people taking prescribed methadone. A re-training programme had been introduced by The Priory following this death but it would 6 7 a | organisation have the power to take such action. — COPIES and PUBLICATION seem that there remains a lack of a detailed appreciation of the risks involved of | death of patients in receipt of methadone and of patients with the particular characteristics of the deceased and therefore until that understanding and appreciation of risk has been determined training which has already being instigated cannot properly deal with issues which have yet to be identified. It is therefore believed that a further review of such risk and risk management policies needs to be considered with suitable re-training introduced thereafter. 2. Evidence was given if a patient enters The Priory with a view to a drug treatment issue then that patient would be screened for drugs. If a patient is admitted to The Priory for an alcohol detoxification programme then there is no screening for drugs. The deceased was known to take methadone. Other drugs were found at post mortem in his system and in combination with alcohol detoxification medication there is an increased risk of respiratory depression and in the absence of the prescribing doctor knowing with a degree of certainty (notwithstanding any statements made by a patient) as to what drugs are ina patients system then a full and proper risk assessment as to the nature of the treatment to be offered and the level of supervision and observations to be instituted (i.e. a meaningful risk assessment) cannot be undertaken and this lacuna in admission procedures could well lead to an increased risk of similar fatalities in the future. ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and | believe your YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 26" 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. | have sent a copy of my report to the Chief Coroner and to the following Interested Persons Beachcroft Solicitors ; sd Royal College of Nursing | MPS Solicitors DWF Solicitors | 1am 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. ANDREW TWEDDLE LLB H M SENIOR CORONER COUNTY DURHAM AND DARLINGTON
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.
PRIORY Director of Safety Priory Group Fifth floor 80 Hammersmith Road London, W14 8UD Email: Tuesday 20 January 2014 Private and confidential Mr Andrew Tweddle HM Senior Coroner for County Durham and Darlington HM Coroners Office PO Box 282 Bishop Auckland Co Durham, DL14 4FY Dear Mr Tweddle Re. Mr David Peter Greenfield (deceased): Regulation 28 Report I write to you further to the Regulation 28 Report which you have issued to the Priory Group in response to your investigation into the death of Mr Greenfield. Your investigation concluded on Wednesday 26 November 2014 and you found that Mr Greenfield had died unexpectedly as a result of his pre-existing natural heart disease combined with respiratory depression linked to obesity and the effects of the ingestion of drugs. You have raised two particular issues of concern in your Regulation 28 Report. I have outlined these issues together with our response: 1. You have identified that not all of the staff who cared for Mr Greenfield were sufficiently experienced in dealing with patients who had both drug and alcohol problems. The risks of respiratory depression in patients such as the deceased were not fully appreciated. I hope that you will be reassured to learn that we have, in response to Mr Greenfield's death and your Regulation 28 Report completed an audit of the competencies of the medical staff working in our specialist wards such as those which provide a detoxification service. The audit has been led by the Priory Group Medical Director Where necessary staff have been transferred to other wards or provided with additional training in the very small number of cases where we have identified individuals have who do not have the full suite of competencies that we would expect. We are taking increasing account of the risks to physical health where there is a co- morbid substance misuse and mental health problems. For example we are ensuring that a full baseline physical health assessment is in place at the point of admission and that potential physical health complications feature more prominently as part of the on-going risk assessment process. With regard to the staff at Aspen Ward, Priory Hospital Middleton St George I hope that you will be reassured to learn that we have introduced a comprehensive training programme for them. The training provided to date has largely consisted of refresher training. We are in the process of sourcing and arranging more advanced level training as a means of ensuring high levels of expertise among the staff team. Additionally I hope that you will be reassured to learn that the Priory Group has amended policy (H21) Non Medical Prescribing to include greater reference to the qualifications and experience of those non-medical staff who are prescribers together with a more detailed outline of the required competencies and the elements of professional development that need to be in place before staff are permitted to prescribe. 2. You have identified that patients who are admitted for alcohol detoxification are not necessarily screened for drugs. You have also pointed out that staff cannot be entirely certain whether a patient has drugs in his /her system due to the limitations in the risk assessment process and the possibility that patients may withhold such information. We are in agreement with you that we should routinely use urine drug screens across all of our detoxification services as part of the assessment process and where necessary on an on-going basis thereafter. Since the inquest we have reviewed this practice and learnt that a number of hospitals are routinely undertaking urine drug screens on those patients who are admitted for alcohol detoxification. Our intention is to ensure that our hospitals all have access to urine drug screening kits and that staff are aware that a test should be undertaken if there is any indication that the patient may be at risk of using illicit drugs prior to or at the point of admission. Our intention is to ensure that these kits are readily available at relevant hospital sites by the end of February 2014. I hope that you will be reassured to learn that the lessons learnt in respect of your investigation into the death of Mr Greenfield will be shared at the forthcoming Priory Group Consultant Psychiatrist Conference which is to be held on Monday 19 January 2014. We will also take the opportunity to integrate the lessons learnt from this tragic incident into our on-line training modules (this is an on-going piece of work however the relevant training modules are all due for review in spring 2015). We will also take the opportunity to raise these matters as part of future safety bulletins and at our internal meetings and conferences for example the lessons learnt from this case were presented at our Medical Directors Meeting which took place on Monday 19 January 2015. I hope that this response provides you with reassurance as to the actions that we have taken and those that we are intending to take to reduce the possibility of an incident of this kind happening in the future. Please do not hesitate to contact me if I can provide you with further advice or assistance in respect of this matter. Yours sincerely, Director of Safety Copies to: Hospital Director: Middleton St George Hospital , Director of Quality, Priory Healthcare Division HE, Group Clinical Risk Manager
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