Prevention of Future Deaths reports · 2015
Regulation 28 report to prevent future deaths, reference 2015-0295, written 23 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 | 23 Jul 2015 |
|---|---|
| Reference | 2015-0295 |
| Deceased | Lynn Poyser |
| Coroner | ARW Forrest |
| Coroner area | South Lincolnshire |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | none published |
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.
AR W Forrest tum, ercp, Frcpath GMC Number: 1333523 Her Majesty's Senior Coroner for South Lincolnshire 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. EE Director Pharmacovigilance, MHRA 2. FP Director CCP, National Institute for Health and Care Excellence, 10 Spring Gardens, London, SW1A 2BU 3. Fe Medical Director Lincolnshire Community Health Services, Bridge House, Unit 16, Sleaford, NG34 8GG CORONER | am ARW Forrest, Senior Coroner for the Coroner's area of South Lincolnshire. 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. 3 INVESTIGATION and INQUEST On 31* March 2014 | commenced an investigation into the death of Lynn POYSER, age 56. The investigation concluded at the end of the inquest on 22" July 2015. The conclusion of the inquest was ACCIDENT. CIRCUMSTANCES OF THE DEATH Lynn suffered from a number of problems including impaired kidney function, fatty liver disease, Type 2 Diabetes Mellitus, Fibromyalgia and heart failure. She was being prescribed 22 different medicines including Spironolactone when she attended her G.P. for a nurse led chronic illness check on 5" March 2014. Her blood pressure was noted to be 144/80. The registered nurse, not a prescriber, printed out a prescription for 2.5mg Lisinopril once daily for Lynn. She took this to the duty doctor in the practice who was not Lynn's regular G.P. After Unit 1, Gilbert Drive, Endeavour Park, Boston PE21 7TQ Tel: 01522 553374 Fax: 01522 516717 Email: HMCoroner_Southlincolnshire@lincolnshire.gov.uk AR W Forrest i, rrcp, FrcPath GMC Number: 1333523 Her Majesty's Senior Coroner for South Lincolnshire Ko discussion the prescription was signed. It was received in a pharmacy adjacent to the practice on 8'" March 2014 and once dispensed was collected by her husband. Arrangements were made for a "blood test", including serum potassium on 24" March 2014. On 22" March 2014 she was admitted to hospital with a serum potassium of 9.7 mmol/L. Despite appropriate treatment she had a cardiac arrest from which she could not be resuscitated. Her vitreous humour at post mortem had a urea concentration of 41.8 mmol / L and a creatinine concentration of 421 mmol / L. The cause of death was recorded as: 1a Hyperkalaemic Cardiac Arrhythmia 1b Acute on Chronic Renal Failure 1c Co-prescription Spironolactone and Lisinopril 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: Evidence was presented at the inquest to the effect that the interaction between Lisinopril and Spironolactone is well known, and that Lisinopril can precipitate deterioration in a patient's renal function. NICE published guidelines on initiation of Angiotensin converting enzyme inhibitor therapy indicates that patients should be reviewed one to two weeks after initiation of therapy and have their renal function and electrolyte status checked 10 — 14 days after initiation of ACEI therapy. This is re- : iterated in LCHS guidance. The expert evidence at the inquest pointed out that, following a report of a trial in 1999 "The Randomised Aldactone Evaluation Study", there was an increase in the co-prescription of Spironolactone and Lisinopril in heart failure, immediately followed by an increase in hospital admissions and subsequent deaths associated with hyperkalaemia. Unit 1, Gilbert Drive, Endeavour Park, Boston PE21 7TQ Tel: 01522 553374 Fax: 01522 516717 Email: HMCoroner_Southlincolnshire@lincolnshire.gov.uk AR W Forrest iu, ercp, ercpath GMC Number: 1333523 Her Majesty's Senior Coroner for South Lincolnshire Those to whom | make this report may wish to consider whether or not the current guidance relating to the co-prescription of ACEI drugs, such as Lisinopril, and Spironolactone draws sufficient attention to the need for caution and the need to take a holistic view of the best interests of the patient. ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and | believe you and/or your organisation have the power to take such action. ae | YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 21° September 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: 1. H- Husband 2. EE son 3: - Daughter | 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. 23 July 2015 ARW Forrest.......... P| SUREUIA Nava devnenctietestarcsen H M Senior Coroner for South Lincolnshire Unit 1, Gilbert Drive, Endeavour Park, Boston PE21 7TQ Tel: 01522 553374 Fax: 01522 516717 Email: HMCoroner_Southlincolnshire@lincolnshire.gov.uk
See every Prevention of Future Deaths report matching Hospital Death (Clinical Procedures and medical management) 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.