Prevention of Future Deaths reports · 2015
Regulation 28 report to prevent future deaths, reference 2015-0262, written 9 Jul 2015. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 9 Jul 2015 |
|---|---|
| Reference | 2015-0262 |
| Deceased | Alun Walters |
| Coroner | Sarah-Jane Richards |
| Coroner area | Powys, Bridgend and Glamorgan Valleys |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | none published |
Text extracted from the PDF text layer. 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. His Honour Judge Peter Thornton QC, Chief Coroner of England and
Wales.
2. Mr. Mark Drakeford, Minister for Health, National Assembly for Wales.
3. Mrs. Allison Williams, Chief Executive, Cwm Taf University Health Board
4.
General Medical Practitioner & Partner, The Lawn Medical
Practice, Rhymney.
Health Board, Division of Primary Care & Networks.
Primary Clinical Director Aneurin Bevan University
, Consultant Psychiatrist, North Community Mental Health
Team.
5.
6.
7.
1
CORONER
I am Dr. Sarah-Jane Richards, Assistant Coroner, for the coroner area of Powys,
Bridgend and Glamorgan Valleys
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 the 27th March, 2015 I commenced an investigation into the death of Mr. Alun
Walters. The investigation concluded at the end of the inquest on the 26th
June, 2015.
The conclusion of the inquest was ‘A gastro-intestinal haemorrhage in the circumstance
of suspected elevated levels of Warfarin and failed INR monitoring’.
4
CIRCUMSTANCES OF THE DEATH
Mr. Alun Walters had longstanding mental health difficulties and alcohol misuse for
which he was receiving community psychiatric support. He had been prescribed
Warfarin as an anticoagulation therapy since 2011 following the receipt of a metallic
heart valve. Mr. Walters was aware of the need for regular INR testing. He joined the
Lawn Medical Practice in 2012 and received weekly Warfarin prescriptions from the
Practice. The Practice was contracted by the Aneurin Bevan University Health Board to
provide INR testing, dosing and prescriptions. Regular INR tests were undertaken until
November 2013. In December 2013 Mr. Walters failed to attend for his routine INR test
which triggered contact by the Practice advising him to continue his INR testing. No
further tests were actually undertaken by the Practice although his prescriptions
continued.
In January, 2015
, the Practice’s Health Care Assistance, happened
1
on 30 January, 2015 advising that he urgently
to see Mr. Walters in town. She noted that she had an INR test at the Practice since
November 2013 and immediately alerted
GP. In consequence, Mr.
Walters was contacted by
needed to attend for INR testing or GP consultation. On 29th
January, 2015 the GP
Practice’s computer prescription data base for Mr. Walters noted that Warfarin was
discontinued. A total of 51 prescriptions had been provided to Mr. Walters without the
benefit of dosage assessment following INR testing.
Pharmacist,
longstanding prescription for Mr. Walters, had been dropped from Mr. Walter’s
prescription list. Believing this to be an error, he continued to provide it. The GP Practice
had not notified the Pharmacy that Mr. Walter’s longstanding prescription of Warfarin
had been discontinued. Both at Inquest and during interview with the Aneurin Bevan
University Health Board’s Pharmacy Advisors,
supplied to Mr. Walters in February to April, 2015 without a valid prescription.
of the Rhymney Pharmacy Ltd. noted that Warfarin, a
admitted that Warfarin was
confirmed at Inquest that he was not aware of the National Patient Safety
Agency’s Safety Alert No. 18 entitled ‘Actions than can make Anticoagulation Therapy
Safer’ dated 27.03.07 which states -
‘Ensure that before dispensing a repeat prescription for anti-coagulation medication,
they check that the patient’s INR is being monitored regularly and that it is at a safe level
for the repeat prescription to be dispensed’.
5
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.
The Lawn Medical Practice -
(1) failed to use any computer software programmes to support its prescription
decisions;
(2) breached its contract with the Aneurin Bevan University Health Board in the
development and maintenance of an anti-coagulation treatment register;
(3) failed to put into place a system of notification to the GP and the Health Care
Assistant of a patient’s failed attendance for INR testing; and
(4) failed to advise the Rhymney Pharmacy Ltd. that Warfarin had been withdrawn due
to a lack of INR safety testing.
6
ACTION SHOULD BE TAKEN
In my opinion action should be taken to prevent future deaths and I believe you and your
organisation have the power to take such action in the area of:
Ensuring pathways of communication are in place in respect of a patient’s
anticoagulation dosing, INR testing, failed attendance for INR testing and
changes of prescription both within the GP Practice and to external agencies
including pharmacies providing anti-coagulation prescriptions; and
ensuring the GP Practice is compliant with its responsibilities of maintaining a
register of patient anticoagulation dosing and testing.
7
YOUR RESPONSE
You are under a duty to respond to this report within 56 days of the date of this report,
namely by 28th
September, 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.
2
8
COPIES and PUBLICATION
I have sent a copy of my report to the Chief Coroner; Mr. Mark Drakeford, Minister of
Health, National Assembly for Wales; Mrs. Allison Williams, Chief Executive, Cwm Taf
University Health Board;
University Health Board, Division of Primary Care & Networks;
Medical Practitioner & Partner, The Lawn Medical Practice, Rhymney;
Consultant Psychiatrist, North Community Mental Health Team; and
Primary Clinical Director Aneurin Bevan
General
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
9th
July 2015 SIGNED:
Dr. Sarah-Jane Richards
HM Assistant Coroner
3
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