Prevention of Future Deaths reports · 2014
Regulation 28 report to prevent future deaths, reference 2014-0526, written 4 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 | 4 Dec 2014 |
|---|---|
| Reference | 2014-0526 |
| Deceased | James Stewart |
| Coroner | Thomas Osborne |
| Coroner area | Bedfordshire & Luton |
| Category | Care Home Health 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.
THOMAS R OSBORNE
Senior Coroner for Bedfordshire and Luton
REGULATION 28 REPORT TO PREVENT FUTURE DEATHS
| MK45 4HR
THIS REPORT IS BEING SENT TO:
The Chief Executive
Bedfordshire Clinical Commissioning Group
Capability House
Silsoe |
Bedfordshire |
i
|
CORONER
Iam Thomas R Osborne, Senior Coroner for Bedfordshire and Luton
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. i
http://www. legislation.gov.uk/ukpga/2009/25/schedule/5/paragraph/7
http://www. legislation.gov.uk/uksi/2013/1629/part/7/made
| INVESTIGATION and INQUEST
| On 23 April 2014 I commenced an Investigation into the death of James
Duncan STEWART aged 84. The Investigation concluded at the end of the
Inquest on 03 November 2014. The conclusion of the inquest was a NARRATIVE
CONCLUSION: The deceased was admitted to Manton Heights Care Home,
Woodlands, Bedford, on the 4th February 2014. He suffered from Parkinson's
Disease and due to a systems failure, from the time that he came into the home,
he was not given his medication because the drug Co-Careldopa was not
included in his list of medication that was requested from the General
Practitioner. He deteriorated and was admitted to Bedford Hospital on the 12th
April 2014 with decreased mobility and responsiveness. He died at Airedale
Nursing Home, 44 Park Avenue, Bedford on the 21st April 2014.
| CIRCUMSTANCES OF THE DEATH
James had been a resident at Manton Heights Nursing Home since 04 February
2014 having come from sheltered housing where he was not coping. Whilst at
Senior Coroner, The Court House, Woburn Street, AMPTHILL, Bedfordshire, MK45 2HX
Tel 0300-300-6559 | Fax 0300-300-8267
|
Manton Heights, it appears that he was not given his Parkinson Disease |
medication and this was only realised once he was admitted to Bedford Hospital
South Wing on 12 April 2014 with decreased mobility and responsiveness.
James was discharged from Bedford Hospital South Wing to the Airedale
Nursing Home for end of life care. He sadly died on the 21 April 2014. His
previous medical history was Parkinson’s Disease, Dementia, Atrial Fibrillation
Peripheral Vascular Disease and Knee replacement.
| CORONER’S CONCERNS
| requested to prescribe medication from a patient’s Nursing Home the details are i
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) There did not appear to be any system whereby when a new GP Practice is |
not checked with the previous Practice. Such a system would have highlighted |
the fact that Mr. Stewart’s Co-Careldopa medication had not been included.
(2) It was felt by those giving evidence from the GP Practice, and from the two
Nursing Homes, that the correct medication to be prescribed should be a matter
for the General Practitioner to confirm rather than relying upon unqualified staff |
from the Home. They also felt that the Clinical Commissioning Group were the :
obvious body to ensure that a robust and consistent system is put in place. :
{
ACTION SHOULD BE TAKEN
In my opinion action should be taken to prevent future deaths and I believe you
have the power to take such action. i
anyon
YOUR RESPONSE
You are under a duty to respond to this report within 56 days of the date of this
Report, namely by 29 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
I have sent a copy of my Report to the Chief Coroner and to the following
Interested Persons:
Senior Coroner, The Court House, Woburn Street, AMPTHILL, Bedfordshire, MK45 2HX
Tel 0300-300-6559 | Fax 0300-300-8267
T
|
| Family
The Airedale Nursing Home
Manton Heights Nursing Home (Ranc Care Group)
| [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. |
Dated 04 December 2014
y
THOMAS R. OSBORNE
Senior Coroner |
for Bedfordshire and Luton
Senior Coroner, The Court House, Woburn Street, AMPTHILL, Bedfordshire, MK45 2HX
Tet 0300-300-6559 | Fax 0300-300-8267
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.
Bedfordshire Clinical Commissioning Group Bedfordshire Clinical Commissioning Group Mr Tom Osbourne Suite 1, Capability House HM Coroner's Office Wrest Park soe The Court House Fo sea Bedfordshire MK45 4HR Woburn Street ack : : cs Ampthill Email; Website: www.bedfordshireccg.nhs.uk Bedfordshire MK45 2HX Your reference: P| Dear Mr Osbourne, Re: Inquest touching the death of James Duncan Stewart inquest held on 03 November 2014 at Coroner,s Office, Ampthill | am writing in response to your Regulation 28 Report to Prevent Further deaths in connection with the above case. Bedfordshire Clinical Commissioning Group was aware of the case and was involved in the work to address issues identified at Manton Heights Care Home. The two matters of concern that you have raised are recognised by our General Practitioner members and our Medicines Management Team: (1) There is currently no standardised system for when a GP practice is requested to prescribe medication for a new patient at a nursing home to include checks with the previous practice. Practices have developed local processes to facilitate accurate prescribing, however these remain subject to inconsistencies and interpretation. The main current IT software (called System One) in primary care does not have a process to share an accurate list of prescribed medicines and there is a delay in transfer of records to the new registered GP. This remains a national IT issue further complicated when GP practices are utilising IT systems which are not compatible (2) It is agreed by our GP members that it is the responsibility of the prescribing GP that the correct medication is prescribed to meet the clinical needs of the person and it should not be dependent upon non-clinical staff in Care Homes to challenge the accuracy of this process. The National Institute for Health and Care Excellence published Guidance SC1, entitled: "Managing Medicines in Care Homes', in March 2014. Section 1.7 outlines the roles and responsibilities for medicines reconciliation when a person is transferred into a Care Home. Following this publication a number of initiatives were implemented to ensure safe transfer of patients including accurate information on prescribed medication. However, there remains the potential for error and mistakes, and incidents are identified through complaints, incidents and safeguarding alerts. better care, better value, better health Use of Information Technology (IT) solutions is key to standardising practice and improving patient safety particularly in relation to medicines management. Initiatives relating to electronic prescribing in acute and primary care which are in discussion stages but are currently underdeveloped across Health and Social Care and remain a barrier to efficient communication processes. We will continue to endeavour to improve IT systems as far as possible locally to improve communication between care providers. In the meantime, in liaison with GP colleagues, Bedfordshire Clinical Commissioning Group have developed a protocol for reconciliation of medications when people are transferred into care homes and are registered with a new GP. The protocol is under consultation with stakeholders in primary and social care. This will also be shared with the commissioners of General Practitioners, NHS England Area Team, for them to consider whether contractual actions can be taken to strengthen compliance with the protocol. An action plan has been written to drive this work forward and progress will be monitored by our Patient Safety and Quality Committee. Please find attached the action plan and draft protocol under consultation. Bedfordshire Clinical Commissioning Group is committed to improving medicines management across the interface of health and social care. Yours sincerely Chief Operating Officer Bedfordshire Clinical Commissioning Group Attachments: Action plan and Draft Protocol
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