Laurence Boyens

Date of report	22 Apr 2015
Reference	2015-0156
Deceased	Laurence Boyens
Coroner	Andrew Harris
Coroner area	London Inner (South)
Category	State Custody related deaths
Source	judiciary.uk record · original PDF
Responses published	2

The report

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.

Senior Coroner, London Inner South, UK
Re: Laurence Boyens, Ei
REGULATION 28 REPORT TO PREVENT FUTURE DEATHS
THIS REPORT IS BEING SENT TO:

1. ES Head Healthcare, HMP Belmarsh,
Western Way, London SE28 0EB

2. [ERE Director of Fitness to Practice, General Midwifery Council

(practice referrals) Standards and Guidance Department, 23 Portland Place,
London W1B IP2

3. coc mer of Fitness to Practice, Fitness to Practice
epartment, General Medical Council, Regent’s Place, 350 Euston Road,
London NW1 3JN

CORONER

Tam Andrew Harris, senior coroner for the jurisdiction of London Inner 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 19th November 2012, | opened an inquest into the death of Mr Laurence Boyens,
who died on 15" November 2012. The inquest was concluded on 25th January 2015.

It was recorded that the medical cause of death was:
1a Methadone, Tramadol and Diazepam intoxication

In their narrative, the jury concluded that death was caused by:
e The combination and interaction of prescribed drugs and
¢ The failure to follow the Clinical Management of Drug Dependence in Adult
Prison Settings Guidelines 12.3 and 12.4, specifically with acting on Laurence
Boyens’s lowering blood pressure.

The jury further recorded:
There was neglect in providing basic medical care by way of the failure to suspend and

withhold Methadone and Tramadol when [he} was exhibiting signs of toxicity on 13th
November, which was a most significant contributing factor to his death

CIRCUMSTANCES OF THE DEATH
The jury also concluded, inter alia, that the following factors had contributed to death:

¢ There was no continuity in monitoring of intoxication symptoms and review
before the administration of medication to be able to assess changes

¢ There was no documented guidance on respiratory assessment with regards to
intoxication and

e There was an inadequate 5 day review, leading to his transfer to House Block 4.

CORONER’S CONCERNS
During the course of the inquest the evidence revealed matters giving rise to concern.
MATTERS OF CONCERN are as foliows.

1, There appeared to be a general misunderstanding how health care
professionais should comply with DH Clinical Management of Drug Dependence in
Adult Prison Settings Guidelines 12.3 and 12.4 b. In particular this relates to the
requirement to ensure that patients who are undergoing Methadone or
Buprenorphine stabilization have not experienced a lowering of blood pressure or
drowsiness before administration of the controlled drug.

e Health care assistants routinely took the blood pressure before
administration but did not inform the nurse of the reading and may not
have had instruction when to report the reading

¢ The evidence of six nurses and a health care assistant showed that
previous blood pressure recordings were not sought or examined to
determine if there had been a lowering of BP

¢ The record of blood pressure was often written on paper and not usually
entered in the medical records at the time and sometimes not at all

¢ Ahealth care assistant who did record a BP of 93/68 was asked by a nurse
to repeat it and reported back to the medication hatch that it was still low.
No apparent action was taken by nurses to suspend the medication or
escalate the concern to a doctor on 11th.

¢ One nurse, who did not see the BP of 93/58 recorded in the records and
administered Methadone, did not know what he would do if he had
discovered a previous higher BP.

¢ One nurse was surprised that a BP of 105/60 having a reading of 128/68
and 93/68 the previous day and 121 /81 the day before that, should trigger
withholding Methadone and escalating to the doctor.

* The expert GP, who had been clinical director in the health care team
provided to the prison, identified a sequence of seven BP recordings over
4 days, six of which (the second was considered rogue) should have
triggered suspension of administration of drugs and escalation to the
doctor, but in no case did this occur.

¢ The head of health care at the time, who was an experienced nurse, did
not accept that advice and asserted it would be impractical to implement
it, as it would lead to significant delays.

¢ Ina local policy on Buprenorphine a threshold triggering suspension of
drug and escalation was defined as 90/60 without reference to the trend.
None was found in a section on Methadone and no definition of lowering
of blood pressure or how to record it was found in any local policies.

¢ No nurse saw the entry in the medical records by a doctor at 18.56 on 13th
November which read: “ Unusually drowsy. Eyelids close when not
engaged. communicative alert. no sadness or dsh. Plan stop Citalopram
and monitor for signs of overdose.. may req further urine test before
further Methadone testing...”

e _At 17.57 on 13th, one hour from the doctor’s assessment, when he must

parmesan

have been unusually drowsy, no nurse found him drowsy when he
presented at the hatch for medication, and he was given Methadone and
Tramadol.

¢ On the morning of 14th he was given further Methadone and Tramadol,
without measuring the blood pressure, or testing, as the previous day was
last day of his Methadone titration regime and his 5 day review.

2. Nurse

Nurse P| was called during the course of the inquest, and although given the
opportunity, did not have legal representation in the proceedings.
The evidence from a himself that caused concern included:
e Ablood pressure of 93/58 was not a worry to be brought to the attention of
a doctor.
¢ Ablood pressure of 93/58 was not an indication to suspend Methadone
and Tramadol administration in a drug titration regime, which he
administered on 13th.
¢ It was outside his knowledge whether Methadone and Tramadol can cause
low blood pressure.
¢ Despite a BP two hours eariier of 93/58 and of 112/58 on the 13th at the 5th
day assessment, the nurse, finding dilated pupils and a report of mild
symptoms at night suggestive of withdrawal, said the BP did not matter as
he was feeling well and recommended an increase in Methadone.
¢ It was not recorded in the records, but it was reported that he was
informed by a health care assistant that Mr Boyens was unusually drowsy
on 13th, and that his cell mate thought so too. He was told of concerns
that Mr Boyens was on the wrong medication and ensured that he saw a
doctor, but did not pass these concerns to the doctor himself.

The head of health care considered that his clinical practice raised concerns in relation
to future risks to patients. He had failed RCGP Part 1. He was currently on leave and she
will be reviewing his performance.

3. Nurse was called during the course of the inquest, and although given the
opportunity, did not have legal representation in the proceedings.

The evidence from Nurse [herself that caused concern about risks to future patients
included:

e She did not record a BP at 18.35 on 10th, or at 09.25 on 11th, prior to
administration of Methadone.

¢ She did not notice a BP of 93/68 recorded on “System One” at 15.27,
before she administered Methadone at 17.50 on 11th.

e She expected the health care assistant to inform her of an abnormal blood
pressure, but has not set any parameters, prior to Methadone

e She never looked at previous blood pressures prior to administering
Methadone.

¢ She never makes respiratory rate recordings in monitoring patients on
controlled drugs

e If she had seen the blood pressure of 134/113 that was recorded at 09.24
on 12th November, she would not do anything different.

* Given that her drug administration clinics were very busy (60 people per
session), she was asked whether it would make any difference to what she
did, if she saw half as many patients, but she said she would still not look
at the blood pressures.

¢ Asked if she had changed her practice in any way since the incident, she
said that she had not.

The Head of Health Care reported that she had failed the RCGP course (part II) and that
very clear performance issues were highlighted in the inquest. Asked why these
concerns were not picked up in supervision, [EEE said that a performance plan was
not necessarily agreed, but the court has now given her enough support to address the
issue, As the supervision process has not been able to resolve what appear to be
serious performance issues over the last 2 years 4 months relating to both nurses, this
report is brought to the attention of both HealthCare UK and the Nursing and Midwifery
Council.

‘a

HEE was represented at the inquest and the following evidence gave rise to
concerns:

« He prescribed Citalopram, Tramadol, Methadone, Diazepam and Sodium
Valproate on 10th to a new patient without seeing him, although probably
in possession of old medical records from previous stay in prison, but not
those from his GP related to the period before detention in prison.

e When he saw the patient on 13th he failed to consider the interactions
between Citalopram and Tramadoi and between Citalopram and
Methadone, both of which the prison expert HEE said were
contraindicated, nor the summative effects of combining Methadone,
Tramadol and Diazepam.

¢ He said that he was not aware whether withdrawal can cause low BP and
thought the BP was measured to see if the patient was withdrawing.

* He said that he did not know whether he should stop Methadone if the BP
was low.

« Mr Boyens was seen by the doctor on 13th, the day after another witness
found him drowsy with “pinned eyes” and a few hours before another
witness found him unsteady and drowsy. He made no record of the state
of the pupils, but did record him as unusually drowsy.

« At that examination, according to his 2013 statement he considered the
patient was drowsy due to lack of sleep; in a 2015 statement he
considered use of illicit drugs and was aware of the possibility of
Methadone toxicity. But he failed to stop these drugs from continuing to
be administered.

* Atthis assessment on 13th he recorded an intention to stop the
Citalopram on the request of the patient, but did not take the simple steps
to cancel the prescription on the computerised record and if he told a
nurse about this instruction it was not recalled or noted by them, and
continued to be administered.

e He gave evidence that he would not administer Naloxone to a patient
unless the patient was blue and unconscious and known to have taken
opiates and did not know any disadvantages of doing so. EE gave
evidence that this was not correct and that Naloxone properly
administered had the potential to save lives.

The court was informed that occa ali received a warning from the GMC. From this
it appears that the last two pieces of evidence above were not known to the GMC. It
further was noted that the GP no longer works in prison health care but as a full time GP
principal, with continued prescribing responsibility for those with drug problems in a
polyclinic. This report is brought to the attention of the GMC so that it can determine
whether the further evidence raises concerns about the safety of current patients of the
doctor, which require action.

ACTION SHOULD BE TAKEN

The following organizations are asked to consider the concerns arising from this case
and whether any action is needed to reduce the risk of other deaths.

With regard to concern (1) Head of Health Care, HMP Belmarsh and Healthcare UK.

With regard to concerns (2) and (3) Nursing and Midwifery Council (practice referrals)
and the Head of Health Care at HMP Belmarsh and Healthcare UK.

with regard to concern (4) General Medical Council (Fitness to Practice Department).

YOUR RESPONSE

You are under a duty to respond to this report within 56 days of the date of this report,
namely by June 12 2015. |, 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:

HEE (Gaughter), next of kin,

it HMP Belmarsh,

for Care UK,
land Nurse Odukoya formerly Harmoni Healthcare at HMP Belmarsh,

former medical director Harmoni for Health, represented by

[ll OOo and former GP, Harmoni at HMP Belmarsh,

Eee SMP Belmarsh,
HE former clinical director and expert,
Managing Director Healthcare UK,
Rt. Hon Jeremy Hunt, Secretary of State for Health

| 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.

If - would like further information about the case _ contact my officer, I

[DATE] [SIGNED BY CORONER]
92nd tl 20. a a

Responses

2 responses 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.

Response from Respondent Not Named (PDF)

18 December 2015
Ale 407 General
In reply please quote: C1-781375998 Medical
Your ref: 02785-12 = — ~ Council
PU DEC 26 3 Hardman Street
Mr John Thompson ” Manchester M3 3AW
Clerk to HM Coroner Email: gmc@gmc-uk.org
Southwark Coroner’s Court Website: www.gmc-uk.org
. Telephone: 0161 923 6602
1 Tennis Street Fax: 0161 923 6201
London
SE1 1YD

Dear Mr Thompson

Regulation 28 Response to a report on action to prevent other deaths
Laurence Boyens

Thank you for your letter of 9 December 2015 and received in our offices on 17
December 2015.

I am sorry that we have not provided the Coroner with our response to the PFD
Report. This was an omission on our part and I can confirm that when we received
the PFD Report in April 2015 we immediately considered the report and whether
we should exercise the power under our rules to review our earlier decision to not
proceed with a complaint about Dr Amayo’s care of Mr Boyens.

For your information, there are two grounds upon which we can consider a review
of the decision. These are that either there is a ‘material flaw’ in the decision or
there is new information that might have led to a different decision. Even if either
of these grounds does apply a review can only take place if there is a ‘public
interest’ in it happening. This would be for a reason related to the protection of
the public, to stop there being an injustice to the doctor or some other compelling
reason.

Where we decide to commence a review we will seek the views of the doctor and
once we have those, we will make a decision as to whether the original decision
should stand or whether the case should be reopened and referred to our senior
decision makers for a fresh decision.

Working with doctors Working for patients ated and Woes nOBSz78}

and Scotland (SC037750)

In light of the information contained within the PFD Report, we decided to
commence a review of our decision to close the case on the ground that there is
new information which may have led to a different decision. We also considered
that a review of the decision was necessary in the public interest.

We have obtained the doctor’s comments and will now pass the case for a
decision. I am advised that the decision will be made by 8 January 2015

I hope this clarifies the action we took following the PFD report and I again
apologise for not letting the Coroner know about this sooner.

I would be happy to take your call if you wish to discuss further.

Yours sincerely

Anthony Omo

Director and General Counsel
Fitness to Practise Directorate
Telephone: 020 7189 5117

Email: aaomo@amc-uk.org

The GMC is a charity registered in

Working with doctors Working for patients England and Wales (1089278)

and Scotland ($C037750)

Response from 2 (PDF)

Nursing &
Midwifery

pT JAS Council
Private and confidential
Mr John Thompson 6 January 2016
Clerk to H M Coroner Case reference:054002/2016
Southwark Coroner's Court Ser/InitialAckCon/Ref
1 Tennis Street Screening Administrator: Chloe Hawkridge
London Direct line: 020 7681 5338
SE11YD Ftp-ScreeningTeam@nmc-uk.org

First class post

Dear Mr Thompson
Fitness to practise referral — Sunita Arjune

Thank you for your recent referral to the Nursing and Midwifery Council (NMC) dated 9
December 2015 which we received from the Office of the Fitness to Practise Director on
5 January 2016.

All new cases go through an initial assessment process. This includes looking at the
nature of the referral and deciding whether we require any further information. We will
then determine how to proceed. After the initial assessment we will write to you with our
decision.

We are committed to improving our customer service and | enclose the standards we
aim to meet.

If you have any questions or need to contact us, please use the contact details shown at
the top of this letter. Should you contact us by telephone, in accordance with our
policies on information security, you will be asked a series of questions to verify your
identity.

Yours sincerely

Chloe Hawkridge

Screening Administrator
Fitness to Practise

Enclosures
e FtP customer service standards.

First Floor, 1 Kemble Street, London WC2B 4AN
T +44 20 7462 5800/5801 F +44 20 7580 3410
DX 37970 Kingsway

www.nmc.org.uk.

The nursing and midwifery regulator for England,
Scotland, Wales and Northern Ireland Page 1 of 4

Registered charity in England and Wales (1091434) and in Scotland {SC038362}

Nursing &
Midwifery
Council

FtP customer service standards

This document sets out the customer service standards we aim to meet. We hope that
whatever the outcome of your contact with us, whether you are a nurse, midwife,
employer, member of the public or any other individual or organisation, that you will be
satisfied with our service.

What you can expect from us in Fitness to Practise

Our customer service promise

To demonstrate our commitment, we have set out our customer service promise —
behaviours which our staff will apply in their dealings with internal and external
customers. We will:

« Be welcoming and courteous.

e Be respectful.

¢ Be helpful and responsive.

« Communicate clearly.

e Treat all people fairly.

¢ Provide information suited to the customer's needs to the best of our ability.

e Be clear and realistic about what we can provide and when.

Using our services

We want our service to be accessible to everyone and can:

e Provide all our printed materiais in different formats and different languages.

e Use the typetalk service.

e Talk to you on the phone in different languages (using an interpreter).

Please let your case officer or contact person know if you have any specific needs that
you would like us to take account of.

Our contact with you

« We want you to understand what is happening with your case.

¢ We will provide you with details of who you can contact in respect of your case.
e We will deal with you in plain English by explaining any complicated terms and

avoiding jargon.

December 2011 Version 1.1 Page 1 of 4

¢ Wewill give you details about the way we work and what you can expect.

Dealing with cases as quickly as possible
When we contact you we will always try to meet the following timescales:
e Telephone messages and voicemails will be returned within 24 hours.

* Emails will be acknowledged by the next working day, stating a date by which a
substantive response will be sent.

e Letters and faxes will be acknowledged within five working days, stating the date by
which the person can expect to receive a substantive response.

e falater date is not agreed then a substantive response will be provided within 20
working days.

The time it takes us to conclude our consideration of your case will vary depending on
what it is about, the availability of witnesses and what information or further
investigation is required. We aim to conclude our enquiries as soon as we can and will
indicate at the start of the process how long we expect them to take, ensuring that we
provide you with updates if timings change.

Please be assured that we will deal with matters as quickly as we can, as we
understand that an investigation is a difficult situation for all concerned.

Confidentiality

If you refer a matter to us, to help us deal with a case effectively we need to send a
copy of your letter or referral form and any supporting information you provide directly to
the nurse or midwife concerned. That is why we ask you to sign the referral form or
complete a separate consent form to say you agree to this, as it is the quickest way to
get started.

Similarly, if you are a nurse or midwife and respond to a complaint, we may copy that
response to the person or organisation that referred the complaint to us. Please be
assured that we comply at ail times with data protection and confidentiality rules. We
are aware that the facts in some cases can contain very sensitive or personal
information, which we will never inappropriately share with other parties.

For more information about this area of our work, please speak to our freedom of
information officer or email foirequest@nmc-uk.org

December 2011 Version 7.1 Page 2 of 4

Feedback about our service

We welcome feedback at any stage in a case, so please do contact us if you have
feedback to provide.

When we close a case, we will ask the person or organisation that referred it to us to
give feedback on how well they think we handled the case, based on our customer
service promise (see above). We will also ask the nurse or midwife and any witnesses
for their feedback. A questionnaire is available on our website and can be accessed via
this link —

http:/Awww.nmc.org.ul/concerns-nurses-midwives/what-we-do/our-customer-service/ftp-
feedback-form

The completed comments provide us with valuable feedback to enable us to continue to
improve our service for the future. We hope that you will complete the questionnaire, as
your comments are very important to us.

Most people have a good experience of the service that we provide, but sometimes
things do go wrong. Our aim is to work with you to find the best solution to any issues
that arise and to learn from them for the future.

If you have any concerns about the time taken to progress a case or how it is being
handled, please contact us. Complaints should be sent to our Safeguarding and
Complaints Manager who will arrange for the relevant staff member to respond to you.
They can be contacted at complaints@nmc-uk.org or at the address details included
below.

On receipt of your concern(s), we will respond within the following timescales:
e = They will acknowledge your concerns within five working days of receiving them.

e They will send you a full response within 20 working days of the acknowledgement.

If you still feel that your concerns have not been answered adequately, you can contact
the relevant head of department to express your concerns. Correspondence for their
attention should also be sent to our Safeguarding and Complaints Manager quoting the
case reference number and the correspondence will be sent to the relevant staff
member for response.

What we expect from you

We expect you to treat our staff politely. If we find that you are not treating our staff
politely, we may decide to restrict how we communicate with you in the future or, in
extreme circumstances, we may decide to stop dealing with you in a certain way (for
example only in writing and not over the telephone, or through a representative only).

We also expect you to send us, as quickly as possible, any documents we ask for and
let us know if you change your address during a case.

December 2011 Version 1.1 Page 3 of 4

As indicated, we will provide you with contact details for your case officer and you
should contact them directly with general queries relating to the case. If you have a
complaint about our service, you should contact us at the following:

Nursing and Midwifery Council
1st Floor, 1 Kemble Street
London WC2B 4AN

Phone: 020 7462 5800
Fax: 020 7580 3410

www.nmec,org.uk

December 2011 Version 1.1 Page 4 of 4

The report

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