Prevention of Future Deaths reports · 2015
Regulation 28 report to prevent future deaths, reference 2015-0170, written 29 Apr 2015. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 29 Apr 2015 |
|---|---|
| Reference | 2015-0170 |
| Deceased | Jorge Castro |
| Coroner | Alan Walsh |
| Coroner area | Manchester (West) |
| Category | Community health care and emergency services 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 (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. ER Senior Partner, Springfield Medical Practice, 384 Liverpool Road, Eccles, Salford. M30 8QD 1 | CORONER I am Alan Peter Walsh HM Area Coroner , for the Coroner Area of Manchester West 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 21% October 2014 I commenced an Investigation into the death of Jorge Emanuel Mousinho Assabay E Castro, 50 years, born on 24" March 1964. The Investigation concluded at the end of the Inquest on 14" April 2015. The medical cause of death was: 1a) Sudden Unexpected Death in Epilepsy 1b) Post-Traumatic Epilepsy 1c) Old Traumatic Head Injuries 2) Alcoholic Ketoacidosis The conclusion of the Inquest was Jorge Emanuel Mousinho Assabay E Castro died as a consequence of Post Traumatic Epilepsy arising from injuries sustained in an accidental fall on a background of alcoholic ketoacidosis in circumstances where he had not received his prescribed anti-epileptic medication for a period of time prior to his death. 4 | CIRCUMSTANCES OF THE DEATH 1. Jorge Emanuel Mousinho Assabay E Castro died at Flat 222, Willowfold, 228 Worsley Road, Winton, Eccles, Salford on the 16" October 2014. 2. On 20" June 2013 Jorge was found unconscious in a street near to his home address at 222 Willowfold, 228 Worsley Road, Winton, Eccles, Salford by a male on his way to work. An investigation by the Greater Manchester Police concluded that there was no evidence of any third party involvement as to how Mr Castro came to be lay in the street and his injuries did not suggest that he had been involved in a road traffic collision nor that he had been the victim of blunt trauma from a weapon. The evidence at the Inquest accepted that it was likely that he had suffered his injuries as a consequence of an accidental fall. Jorge was taken to the Salford Royal Hospital, where he had surgery on the 20" June 2013, being a right fronto-temporal craniotomy to evacuate an extradural haematoma, and he was transferred to the Intensive Care | Unit followed by the High Dependency Unit. He was known to have had - three seizures following the injury and prior to the surgery. 3. Jorge was discharged from the Salford Royal Hospital on the 14 August 2013 and he was prescribed sodium valproate as an anti-epileptic medication and the prescription of sodium valproate was 300mg three times a day with vitamins. Seizures noted in the period after a traumatic brain injury constitute immediate seizures and need not have any predictive value for future seizure disorder so at the time of discharge the sodium valproate medication was prescribed as a prophylaxis. However Jorge suffered another seizure in February 2014, which led to the diagnosis of Post Traumatic Epilepsy, and at that time sodium valproate was prescribed as a regular medication and not as prophylaxis but there was no reason to increase the dose of sodium valproate. 4. Following his discharge from Salford Royal Hospital, on the 14" August 2013, Jorge was monitored by nn who is a Consultant in Rehabilitation Medicine a e Hospital, and his prescriptions for sodium valproate were issued by his General Practitioner at Springfield Medical Centre, 384 Liverpool Road, Eccles, Manchester. The prescription for sodium valproate was issued on a four weekly basis for the collection of the prescribed medication from the pharmacy on a weekly basis in a Venelink container. 5. There were concerns with regard to Jorge’s compliance with medication and, following a review ) a 8" April 2014, ae : letter date April 2014 to as : eneral Pra Itioner at Springfield Medical Centre, confirming details of the review. The letter confirmed that sodium valproate 300mg tds should continue but the letter stated ‘the issue appears to be mainly with his regular adherence with his anti-epileptics. At the moment I have advised him to continue with Sodium Valproate 300mg tds. If there is one more episode of seizure I think we need to increase it to 400mg tds. At the moment I have not considered any antidepressants for him as he is keeping himself busy in the community. I shall see him in this clinic in six months’ time as routine.’ a 2 2< the next review in his clinic for the 24" October : 6. General Practitioners at the Springfield Medical Centre continued to issue prescriptions for sodium valproate and reviewed Jorge at consuitations arranged by appointment. The General Practitioner notes showed that the last prescription for sodium valproate was dated 2" June 2014 and the prescription would allow Jorge to collect the Venelink container weekly with the final collection of sodium valproate under that rescription for the week commencing 26" June 2014. No further prescriptions were collected by Jorge so that the last Venelink container received by him was dated 26" June 2014 for a period of seven days, which expired on 3% July 2014. Accordingly, Jorge did not receive sodium valproate for the period from 3% July 2014 until the time of his death on the 16" October 2014. 7. Evidence was given at the Inquest that Jorge was seen on three occasions at the Springfield Medical Centre after the 3% July 2014 namely, on the 25" July 2014, on the 11° August 2014 and on the 18" September 2014. Jorge was seen on each occasion by a General Practitioner but his medication was not mentioned and there was no discussion in relation to the fact that he had not collected his prescription for sodium valproate for use after 3 July 2014 and there was no review of the reference in MM letter to the issue that Jorge had with regard to his ‘regular adherence with his anti- epileptics’ 8. The consultations with General Practitioners after 3 July 2014 are referred to in the General Practitioner's notes and the notes record as follows: i. 25" July 2014 — Health check followed by consultation with General Practitioner due to the fact that Jorge admitted feeling low at times but denied any suicidal intent or self-harm. Jorge was advised regarding appropriate services if necessary eg. Crisis Team or GP. ii. 11" August 2014 — Jorge’s diastolic blood pressure readings were found to be slightly elevated and it was arranged for him to have ambulatory blood pressure monitoring and and ECG, the results of which were both normal. ii. 18" September 2014 — Jorge attended with ongoing symptoms of low mood and anxiety together with poor appetite and a variable sleep pattern. It was agreed that treatment with Citalopram should commence and Jorge was advised regarding his alcohol intake and he said that he would engage with the Community Alcohol Team. There was a plan for a further review by the General Practitioner on the 2™ October 2014 but Jorge did not attend the review. 9. On the 16™ October 2014 Jorge was found in a collapsed and unresponsive condition, having died at his home address at Flat 222 Willowfold, 228 Worsley Road, Winton, Eccles, Salford. 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. During the Inquest evidence was heard that: Jorge had not received sodium valproate medication for administration after 3 July 2014 and he had been diagnosed with post traumatic epilepsy in February 2014 requiring regular treatment with sodium valproate as an anti-epileptic medication. Jorge had been seen by General Practitioners at the Springfield Medical Centre on three occasions after the 3” July 2014 without any review of the fact that he had not collected prescriptions for sodium valproate and the fact that the General Practitioner had received a letter from alerting the General Practitioner to an issue in relation to his regular adherence with his anti-epileptic medication. Jorge was known to be a vulnerable person, who consumed excess amounts of alcohol on a regular basis and who was being treated with Citalopram for depression prior to his injuries on the 20" June 2013 and subsequently on the 18 September 2014 prior to his death. The General Practitioner's surgery at Springfield Medical Centre does not appear to have any systems to identify and highlight a patient who has not collected prescriptions, particularly in relation to vulnerable patients who will be dependent on medication for the control of a diagnosed condition and, as in the case of Jorge, to reduce the risk of episodes of seizure. In particular the computerised records do not have a system of highlighting any outstanding prescriptions at subsequent consultations so that a General Practitioner was not alerted to the fact that Jorge had not collected his prescriptions and would not have had a supply of his anti-epileptic medication after the 3” July 2014 at any of the appointments following the 3 July 2014. The evidence raised concerns that there is a risk that future deaths will occur unless action is taken to review the above issues. 2. I request you to consider the above concerns, particularly with regard to the following: The procedures and systems to highlight and alert General Practitioners in relation to concerns or issues raised by a Hospital Consultant, namely in Jorge’s case by ee regard to Jorge’s regular adherence with his anti-epileptic medication. A review of your systems and procedures to alert General Practitioners in relation to the issue of prescriptions and_the failure of a patient to collect prescriptions for prescribed medications, particularly in relation to vulnerable patients who have not collected or received their prescriptions for a period of time. iii. Training of all staff, both professional and administrative, in relation to record keeping and checks in relation to outstanding prescriptions, particularly when a vulnerable patient has not collected a prescription and has not received necessary and prescribed medications for a period of time. 6 | ACTION SHOULD BE TAKEN In my opinion urgent 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 24" June 2015. I, the Area 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 Persons 1. po Sister of Jorge Emanuel Mousinho Assabay E Castro 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. i] 29.04.2015 Dated Signed Alan P Walsh
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.
Springfield Medical Centre | 384 Liverpool Road, Eccles, po Manchester. M30 8QD Po Tel: 0164 871 2450 Fax: 0161 707 0402 Ref:RDJ/ST 19 June 2015 Mr A P Walsh H M Coroner’s Court Paderborn House Howell Croft North Bolton BL11QY Dear Mr Walsh, Your ret: JORGE EMANUEL MOUZINHO ASSABAY E CASTRO - Deceased We write in response to your letter and report dated 29th April 2015 in relation to the death of Mr Castro. Springfield Medical Centre has deep regret at the loss of life of Mr Castro and offers its heartfelt condolences to his family. We strive to provide the highest standard of care to all our patients and as patient welfare is our upmost priority we have carefully reflected on your report, which has raised certain concerns. We discussed this significant event at practice level and have sought advice from Greater Manchester Medicines Management Group. We set out our detailed responses below, which includes the introduction of revised procedures and systems, to better support patients, in particular, in the area of prescription monitoring and compliance. 1. Procedures and systems to highlight & alert General practitioners with regard to poor adherence with regular prescribed medication Springfield Medical Centre had received a letter from (consultant in rehabilitation medicine) dated 8th April 2014, which highlighted the issue with “regular adherence with his anti-epileptics”. The letter also stated that Mr Castro had been “advised” regarding the need to continue with his Practice Manager: Lyndsay Rodway Assistant Practice Manager: FY Springfield Medical Centre 384 Liverpool Road, Eccles, Manchester. M30 8QD Tel: 0161 871 2450 Fax: 0161 707 0402 medication. As a practice we have considered how our IT system can support the practice team in alerting us to similar issues with patients. It is possible for an alert to flag up when any member of staff enters the patient's records and this will now be implemented for any patients who, similar to Mr Castro, are known to have compliance issues with their medication. All practice staff, clinical and administrative, have been advised to inform the practice management team immediately of any patient where compliance issues have been raised by family, carers or any other health care professionals. The management team will then ensure that an alert is activated on the patient’s records. 2. Systems and procedures to alert General Practitioners in relation to the issue of prescriptions that are overdue or have not been collected Mr Castro's social worker had raised concerns regarding his mood on 18th July 2014 and thus an appointment with the General Practitioner was arranged. At this consultation Mr Castro “admitted feeling low at times but denied any suicidal intent or self -harm’. Mr Castro declined medication or psychological support and so he was advised how to access help in the future should his symptoms deteriorate. There was a further telephone consultation with the social worker on 22nd August 2014 where she raised similar concerns again regarding his mood. An appointment was arranged but Mr Castro did not attend. On 18th September 2014 Mr Castro attended an appointment with the General Practitioner. He was accompanied by his social worker and on-going issues with low mood were discussed. At this consultation it was agreed to commence antidepressant medication. His regular repeat medication was considered prior to the new prescription being generated but unfortunately the date of last issue was not noted & the IT system did not highlight that these medications were overdue. The issue of epilepsy and compliance with medication was not raised by the patient or the social worker and in fact the social worker confirmed in a courtesy letter the following day that Mr Castro was “able to manage his personal care” including “medication”. As a practice we regret that Mr Castro’s lack of compliance with medication was not identified during his appointments and we have considered carefully how this may be avoided in the future. We have sought advice from our IT system providers & the Greater Manchester Medicines Management Group regarding overdue prescriptions. It is possible for all overdue prescriptions to be highlighted on the repeat medication screen. This was in place on our systems when Mr Castro was seen but the timescales set were for 6 months overdue. Mr Castro's overdue prescriptions fell short of this time period at each consultation and thus were not highlighted to the general practitioner. However, we have been advised that it is possible to amend this Practice Manager fil Assistant Practice Manager: PY Springfield Medical Centre 384 Liverpool Road, Eccles, Manchester. M30 8QD Tel: 0161 871 2450 Fax: 0161 707 0402 time period and the practice has made the necessary amendments so that in future any staff viewing a patient’s prescriptions will be alerted sooner (from 3 months) and appropriate action can be taken to mitigate any risk to the patient. This would include immediate notification to the General Practitioner who would then liaise with the patient, carers, family and pharmacy as appropriate. The practice can then work with all necessary individuals or agencies to help support the patient with compliance of their medication. However, even this system has its limitations, as it would only highlight the issue of overdue prescriptions when a member of the practice team is actually in the patient’s records and looking at the repeat medication screen. As a practice we have over 3000 patients on regular repeat medication. Each prescription is usually for 1 to 2 months duration. However, approximately 300 of these patients, like Mr. Castro, are issued medications on a weekly basis. This system is usually for patient safety or as a compliance aid. We have thus decided to create a register of all patients who are receiving prescriptions on a weekly basis. These prescriptions are issued in 4 weekly batches and the administrative staff will be checking the prescriptions have been issued for each patient every month. Those that have not been issued will be passed to a General Practitioner for review. Weekly prescriptions are all sent to the patient's nominated pharmacy. We have written to our local pharmacies and asked them to kindly inform us if there is any interruption to any of these patients’ medication collection or supply. 3. Training of all staff in relation to prescribing As a practice we have taken this opportunity to look at our prescribing systems and the changes above do require staff training. However, we have also looked at the possibility of external facilitators who may bring further advice and expertise to the practice on effective management of repeat prescribing. We can confirm that a half-day workshop has been arranged for Thursday 25th June and we would be open to any further recommendations on this day. Once again we are deeply sorry for the loss of life of Mr Castro. Below is a summary of the changes we have/will be implementing: 1. Alert in patient records if issues with compliance have been raised (with immediate effect) 2. Amendment to IT system so overdue prescriptions will be highlighted sooner (with immediate effect) Practice Manager Assistant Practice Manager ln Springfield Medical Centre 384 Liverpool Road, Eccles, Manchester. M30 8QD Tel: 0161 871 2450 Fax: 0161 707 0402 3. Register of patients who are receiving weekly prescriptions (completed but will be updated regularly as more patients are commenced on weekly prescriptions) 4. Notification and discussion of this significant event and collaboration with local pharmacies (completed) 5. Training workshop for all staff involved in repeat prescription generation to support implementation of systems & procedures as above (25th June 2015) As a practice we hope that the above measures can help to support patients with the compliance of their medication by using a more rapid alerting system together with collaboration with pharmacies and other agencies working with patients and sharing their care. Yours sincerely Tadu, For and on behalf of all partners of Springfield Medical Centre Practice Manager Assistant Practice Manager:
See every Prevention of Future Deaths report matching Community health care and emergency services related deaths, and how often a new one appears.
What would an alert for this have sent me? Search the full text
Free to try — the preview shows the real matches and how many arrived in the last 12 months. Your first email alert is free.
These reports are published by the Chief Coroner's office at judiciary.uk and are © Crown copyright. The text here is reproduced from the published PDF so it can be searched. If something on this page is wrong, or you are a person named in it and want it reviewed, email drcjar@gmail.com and we will act promptly.