Prevention of Future Deaths reports · 2014
Regulation 28 report to prevent future deaths, reference 2014-0524, written 2 Dec 2014. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 2 Dec 2014 |
|---|---|
| Reference | 2014-0524 |
| Deceased | Moses McDonald |
| Coroner | Lorna Tagliavini |
| Coroner area | London Inner (South) |
| 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.
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. lon and Maudsley NHS, j ist 2. Stim cote) - iil: Russell-Cooke solicitors 3. (partner) 4. The Chief Coroner CORONER tam Lorna Tagliavini, assistant coroner, for the coroner area of Inner London South 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. INVESTIGATION and INQUEST On 3 April 2013 | commenced an investigation into the death of Moses Andrew Arthur McDonald aged 30 years. The investigation concluded at the end of the inquest on 27 November 2014. The conclusion of the inquest was: “The deceased died as a result of a rare but well-known complication associated with the anti-psychotic medication Clozapine contributed to by a lack of regular glucose testing.” The case of death was given by the pathologist as: 1a. Aspiration of stomach content 1b. Diabetic ketoacidosis CIRCUMSTANCES OF THE DEATH Mr McDonald had long been diagnosed with Paranoid Schizophrenia. In June 2012 he was prescribed Clozapine in tablet form 150 mg BD and was therefore required to attend for regular blood testing to monitor his white cell count. Mr McDonald regularly attended for these mandatory blood tests and nothing untoward was found. However, his first and last glucose test in May 2012 was recorded at 7.4 and thereafter he was not re-tested for his glucose levels either by the Clozapine clinic or by his GP (having missed his last annual health check-up in February 2013). In March 2013 Mr McDonald complained of frequent urination and extreme thirst whilst on holiday and after his return. On 2 April 2013 Mr McDonald was found deceased at his home address, not having undergone any glucose testing since May 2012. cn 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. — 1am aware of the steps that have already been taken to remedy area of concern in the Level One Investigation Report dated 15 August 2013 (draft). However, this does not address: (1) The lack of mandatory and regular glucose testing while on antipsychotic medication by the Clozapine clinic. ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and | believe your organisation 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 within 56 days of the date of this report i.e. by 31 January 2015 (excluding Christmas, boxing and New Year's Day). |, 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 Inter: Persons South. jaudsley NHS Foundation Trust, (mother) and (partner) !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. 2 December 2014 LM ee assi ‘ant coroner,
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 London and Maudsley INHS| NHS Foundation Trust Trust Headquarters 4° Floor Administration Maudsiey Hospital Denmark Hill London SES 8AZ Telephone: 020 3228 2415 Fax: 020 3228 2362 SLaM Switchboard: 020 3228 6000 30'" January 2015 Ms Lorna Tagliavini Assistant Coroner Southwark Coroners Court 1 Tennis Street Southwark SEI 1YD Dear Ms Tagliavini, Re Moses Andrew Arthur McDonald, Died 2™ April 2013, Case Ref: 883-2013 I write in response to the Regulation 28 Report to Prevent Future Deaths dated am December 2014, which you sent following the Inquest into the death of Mr McDonald. In the report, you raised concerns relating to the lack of mandatory and regular glucose testing while on antipsychotic medication by the Clozapine clinic. My response and details of actions taken by the Trust are listed below. Glucose Testing for Patients Prescribed Anti-Psychotic Medication The current physical healthcare policy has recently been updated and outlines the responsibility of each member of clinical staff to address the physical health needs of all patients. The Trust publishes the Maudsley Prescribing Guidelines, which is used throughout the UK and internationally as guidance for prescribers, The physical healthcare policy includes reference to these guidelines for those patients who are prescribed Clozapine. Ideal monitoring would include a fasting blood glucose or a glucose tolerance test after a month, then every 4-6 months. The recommended minimum monitoring is a urine glucose and random blood glucose before Clozapine is started, and repeated every 12 months, with regular monitoring of symptoms of fatigue, thirst, polyuria and candida infection. The Trust considers this monitoring as essential for patients on Clozapine. The policy also outlines the expectation that all patients prescribed anti L.Tagliavini— Ref: 883-2013 - MAA McD — 30.01.15 www.siam.nhs.uk psychotic medication, which has the potential to impact on their physical health, should have a physical health care plan. In order to monitor compliance with the Maudsley Prescribing Guidelines, specifically relating to the physical health monitoring recommendations the Trust pharmacy team carry out regular audits and feedback to clinical services. Specifically within the Adult Mental Health pathway (AMH) the Trust provides training for clinical staff on medication management. Trainers have recently incorporated specific training for staff on Clozapine management covering issues relating to Trust policy and practice guidance. All Promoting Recovery teams have now identified physical healthcare leads whose remit include improving and maintaining standards and ensuring physical healthcare audits are completed and acted upon routinely. There are robust team processes in place in all teams across the AMH pathway which includes daily planning meetings, clinical formation meetings and monthly clinical supervision where it is expected that clinical staff discuss, review and raise concerns about any patient who may be experiencing adverse effects from their medication including Clozapine. In addition in order to learn lessons from previous incidents clinical staff now receives regular feedback from the monthly learning lessons forums. These forums have representation from all pathways and boroughs. Function of the Clozapine Clinic The Trust, having reviewed the situation, has found that Clozapine clinics across the Trust operate differently in each Borough and there is a lack of clarity and consistency in relation to operational processes, resources, management responsibilities and function of these clinics. In order to improve consistency of care provision and clarity of roles and responsibilities of physical health monitoring for patients attending the clinic the following actions will be taken within the next 6 months. The Trust will carry out a full review of the Clozapine clinics across the 4 boroughs with the aim of: e Reviewing the existing operational processes, resources, management responsibilities and function of the Clozapine clinics in each borough — Croydon, Lewisham, Southwark and Lambeth e Determining the core function of these clinics e Clarifying the management roles, responsibilities and reporting structures within each clinic. e Setting core standards of practice across all 4 boroughs Progress will be monitored and reported through the Trust Physical Healthcare committee and issues escalated as necessary to the Trust Quality Sub Committee. L.Tagliavini — Ref: 883-2013 - MAA McD - 30.01.15 2 www.slam.nhs.uk I hope that this letter addresses the issues that you have raised and I would like to thank you for bringing your concerns to my attention. Yours sincerely Medical Director L.Tagliavini — Ref: 883-2013 - MAA McD — 30.01.15 www.slam.nhs.uk
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