Stephen Morris

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. 

 General Practitioner, The Knoll Surgery Partnership, 
Princeway Health Centre, 2 Princeway, Frodsham, Cheshire, WA6 6RX 

CORONER 

I am Alan Wilson, Senior Coroner, for the area of Blackpool & Fylde 

2 

CORONER’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. 

3 

INVESTIGATION and INQUEST 

On 21st June 2013 an investigation commenced into the death of Stephen James 
Morris, aged 44 years. The investigation concluded at the end of the inquest on 15th 
October 2013. 

The record of the inquest confirmed as follows:  

The Medical cause of death was 
1a 
1b 
1c 

Aspiration pneumonitis                                                         
Inhalation of Gastric Contents                                                            
Combined toxic effects of Lithium and Mirtazapine                              

The conclusion of the Coroner as to the death was 
Stephen Morris took his own life                        

4 

CIRCUMSTANCES OF THE DEATH 

As regards the circumstances by which the Deceased came by his death, the inquest 
concluded that Stephen James Morris had previously been diagnosed as suffering from 
bi-polar affective disorder a number of years ago. Having spoken on the telephone to his 
family during the evening of Sunday 16th June 2013 he was found deceased at 
approximately 1015 hours the following morning lying in the bath at the flat where he 
resided. A subsequent post mortem examination confirmed the presence of high levels 
of mood stabilising and anti – depressant medication the combined effects of which 
proved fatal. 

5 

CORONER’S CONCERNS 

1

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
         
                                                   
 
                      
 
 
 
 
 
 
 
 
 
 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.  –  

At the conclusion of the inquest, I indicated to the Properly Interested Persons that I 
proposed to write to the Trust by way of a report in accordance with the provisions of 
paragraph 7 of Schedule 5 of the Coroners and Justice Act 2009. 

At the conclusion of the inquest, I indicated to the Properly Interested Persons that I 
proposed to write to the Trust by way of a report in accordance with the provisions of 
paragraph 7 of Schedule 5 of the Coroners and Justice Act 2009. 

During the Inquiry, I received evidence from you that during a consultation at your 
surgery with the Deceased on 7th March 2013 Mirtazapine medication was prescribed for 
Stephen James Morris, a Patient of your surgery and one you knew had previously been 
referred to the Community Mental Health Team at the Cheshire & Wirral Partnership 
NHS Trust.  

Such medication was prescribed despite the fact that you were aware that such 
medication may not have been the preferred medication for someone previously 
diagnosed as suffering from Bi-polar affective disorder, and upon verbal information 
provided to you by the Patient himself who informed you that this was in accordance 
with the care and treatment being provided by the Community Mental Health Team.  

Having concluded this inquest, I now write to you to confirm that in my view you should 
take action because: 

 

I am concerned that medication was prescribed to a Patient you knew had 
previously been referred to the local hospital Trust in respect of his mental 
health and the diagnosis that had been made. 

  That you prescribed the medication on the basis of verbal information provided 
by the Patient rather than seeking some confirmation form those within the 
Hospital Trust with responsibility for the Patient’s mental health care provision. 
  That knowing the diagnosis, you prescribed medication you acknowledged was 
not the preferred medication for this Patient’s condition and seemingly in the 
absence of discussion with those who had responsibility for the Patient’s mental 
health care. 

I would therefore be obliged if the Trust would write to me in due course to confirm what 
steps if any you propose to take to address these concerns.   

6 

ACTION SHOULD BE TAKEN 

In my opinion action should be taken to prevent future deaths and I believe you 
[AND/OR your organisation] have the power to take such action.  

7 

YOUR RESPONSE 

You are under a duty to respond to this report within 56 days of the date of this report, 
namely by 23rd 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. 

8 

COPIES and PUBLICATION 

I have sent a copy of my report to the Chief Coroner and to the following Interested 

2

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 Persons  

The family of Stephen James Morris 
The Chief Coroner of England & Wales 
The Lancashire Care NHS Foundation Trust 
The Cheshire and Wirral NHS Foundation Trust 

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. 

9 

A.A.Wilson 

Alan Wilson 
Senior Coroner for the area of Blackpool & Fylde 

Dated: 29th August 2014  

3

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Date: 20" February 2015

URGENT - RESPONSE TO REGULATION 28 REPORT
By Post & By Email: coroners@blackpool.gov.uk

Dear Mr Wilson

MDU Member

Inquest touching on the death of Steven James Morris (Date of Death — 17" June 2013)
Regulation 28 Report request

I write following your letter dated 11" February 2015, the contents of which have been noted.

Thank you for confirming thatliEE was not called to give evidence in the capacity of an Interested Person
and accordingly, was not provided with notice of your intention to issue the Regulation 28 report.

I also note that you confirm that this matter was not a causative one, in that any concerns expressed in the
Regulation 28 report did not cause or contribute to the death of Mr Morris. The position seems to be that the
report was issued in an ancillary capacity.

Coroners are clearly given wide discretion as to whether or not in their judgement a Regulation 28 report ought to
be made to prevent future deaths. The guidance to Coroners sets out that ‘it is a pre-condition to making a
report that “the coroner has considered all the documents, evidence and information and that in the opinion of the
coroner is relevant to the investigation”. There is also a requirement that Coroners "should be careful, particularly
when reporting about something specific, to base their report on clear evidence at the inquest or on clear
information during the investigation...” It is unfortunate that these key points in the guidance appear not to have
been followed in this case.

In the light of the supporting evidence that is being provided, it would appear entirely unreasonable and
inappropriate for a Regulation 28 Report in the form and wording it appears to have been directed to ir
the relevant GP records had been requested and reviewed fully during the inquest process, it is respectfully
submitted that the concerns expressed would have been allayed.

Notwithstanding the above, this response is being provided in the capacity of a formal response. It is emphasised
that is responding without having the benefit of reviewing the statements of any of the other witnesses
who attended the first day of the inquest (23 September 2014). EEE was unable to attend on that day and
was therefore called to give evidence separately on 15"" October 2014.

I adopt the wording as set out in section 5 of the Regulation 28 Report and provide [J responses with
supporting evidence.

MDU Services Limited (MDUSL) is authorised and regulated by the Financial Conduct Authority for insurance mediation and consumer credit activities only. MDUSL is an agent for
The Medical Defence Union Limited (MDU). MDU is not an insurance company. The benefits of MDU membership are all discretionary and are subject to the Memorandum and
Articles of Association.

MDU Services Limited, registered in England 3957086. Registered Office: One Canada Square, London E14 5GS

“I am concerned that medication was prescribed to a patient you knew had previously been referred
to the local hospital Trust is respect of his mental health and the diagnosis that had been made.”

The nature of the concern expressed in this point is unclear. Given the multi-disciplinary approach of medical care
within the NHS, it is entirely conventional for GP to prescribe medication in line with recommendations from other
medical practitioners from the Hospital Trust or from tertiary services.

“That you prescribed the medication on the basis of verbal information provided by the Patient
rather than seeking some confirmation from those within the Hospital Trust with responsibility for
the Patient’s medical health care provision.”

This is incorrect. It is clear from the GP records and | evidence that following his consultation, he
telephoned office and verified the position as to the recommendations made by the Community
Nurse Practitioner. J however confirms that it is his standard practice to verify information from the
patients as to medication changes and he did so in this case by telephoning Me. From an
administration perspective jt will ensure that he in future requests that the Consultant Psychiatrist or
Community Nurse Practitioner confirm any change of prescription in writing. Given that the patient was deemed
to require that medication, it would have been inappropriate for to have deferred issuing the prescription
pending the receipt of written confirmation. If he had done so, this could well have formed adequate grounds for
a complaint against J and could have broken down the doctor-patient relationship.

Within the GP records, there is a letter dated 17 June 2013 from the deceased's Psychiatrist
(copy enclosed) which confirms that he was aware of the medication that the deceased was taking as at 4" June
2013, the date of their consultation. Under “Current medication”, he lists "Mirtazapine 45mg od” and also ‘Lithium
1200mg daily”. He states in his letter "J have not made any changes to his current medication as he tells me that
he is happy with this although the treatment regime he is on isn’t ideal for a diagnosis of Bipolar Disorder, i.e The
anti-depressant, Ideally, I would like to see Steven for a longer appointment to be able to take detailed
history...we will try to arrange that for the future.”

It is evident that a Consultant Psychiatrist had a consultation with the deceased some one month after [a
prescription and did not express sufficient concern to change the medication regime in place.

"That knowing the diagnosis, you prescribed medication you acknowledged was not the preferred
medication for this Patient’s condition and seemingly in the absence of discussion with those who
had responsibility for the Patient’s mental health care.”

It would appear that when Sa gave evidence, he reiterated the comments of | OQ the letter
dated 17" June 2013. Please refer to the points made above.

It is highly pertinent that the medical records reveal that the deceased was on a medication regime including
Mirtazapine (45mg daily) together with Lithium (200mg — six times a day) from around May 2009 to December
2011 continuously without any reported issues and there are many items of correspondence from previous
treating Psychiatrists setting out this regime during that period without any concerns being raised. (Extract of
medical records enclosed.)

There is a relationship of trust and confidence between a doctor and patient and a doctor must take in good faith
a history given by a patient, especially where there are no concerns about the reliability of the information given.
Atthoush ca had no concerns of that nature about the deceased, in line with his standard practice, he did
take the step of verifying the information given to him as has already been set out.

I would be grateful if you could proceed to serve this letter on the Chief Coroner in the capacity of
response to the Regulation 28 report dated 1S December 2014.

Yours sincerely

Fatéma Begum
Solicitor

Enc.

1. EE statement to coroner dated &" August 2013

2. HEN tter ated 17" June 2013
3. Extracts of GP Records