Prevention of Future Deaths reports · 2015
Regulation 28 report to prevent future deaths, reference 2015-0375, written 13 Oct 2015. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 13 Oct 2015 |
|---|---|
| Reference | 2015-0375 |
| Deceased | Nathaniel Phillips |
| Coroner | Joanne Kearsley |
| Coroner area | Manchester South |
| 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 REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: The Department Of Health, Richmond House 79 Whitehall, London, SW1A 2NS | CORONER Tam Joanne Kearsley Area Coroner, for the Coroner area of South Manchester 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 | INVESTIGATION and INQUEST On the 29" September 2015 I concluded the Inquest into the death of Nathaniel Luke Phillips born on the 18 May 1990 who died on the 15" April 2015 at Tameside General Hospital. The cause of death was confirmed as la) Hypoxic Brain Injury due to 1b) Acute Asthma Attack. ri CIRCUMSTANCES OF THE DEATH The circumstances of Nathaniels’ death are as follows: During the course of the Inquest the Court heard evidence from a number of witnesses including Nathaniels’ Mother and also his General Practitioner. Nathaniel had been diagnosed with asthma as a child. He had a diagnosis of brittle asthma. For reasons which were unclear and which are currently being reviewed by his GP Nathaniel seems to have been lost to Adult Asthma Services once he was too old for the Paediatric services. He was last seen in his GP practice in April 2014. His last prescription for his asthma medication was issued in July 2014. In January and February 2015 Nathaniel presented twice to the emergency department following an acute exacerbation of his asthma. The Court heard that the reason Nathaniel did not collect any prescriptions for his asthma medication was because of the cost of the regular prescriptions. During this time he used inhalers which were prescribed to family members, several of whom were on the same medication. However the evidence from his GP confirmed that the lack of prescriptions issued meant that this indicated to them that Nathaniel was not requiring medication and that his asthma was therefore being controlled. It was confirmed that if the accurate situation had been known this may have led to an increase or alteration of his asthma medication. On the 13" April 2015 at 23.42 hours Nathaniel called an ambulance as he was having an acute exacerbation of his asthma. The Court heard his call to the ambulance service during which he was able to speak and provide all the requested information. As a result of the information provided the call was classed as requiring an ambulance within 20 minutes (according to local protocols). Unfortunately there were no ambulances available. At 00.13 hours Nathaniel makes a second call to the ambulance service, in this call his condition has clearly deteriorated. The Call handler from the ambulance service correctly increases the response code to a code red (requiring an ambulance within 7 minutes). Again there were no ambulances available and it was not until 00.22 that an ambulance was allocated. At this time, Nathaniels girlfriend arrives at the property and upon seeing Daniel speaks to the call handler who is still on an open telephone line and says that she is going to take Nathaniel in the car to the hospital. She is advised that an ambulance is now on its way but decides to take him. Whilst enroute Nathaniel collapses in the car. At hospital it is confirmed that he has suffered a severe lack of oxygen to his brain. CORONER’S CONCERNS One of the concerns raised by the family and the GP was that a diagnosis of brittle asthma is not one of the illnesses covered by the medical exemption certificate, despite the fact that it is a life-threatening condition requiring medication. It was confirmed that illnesses such as diabetes and epilepsy which require continuous medication are covered. As indicated earlier due to the cost of his constant medication Nathaniel did not always collect regular prescriptions and relied on family members asthma medication. This meant his GP did not escalate his case or reassess his requirements and asthma control. ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and | believe you have the power to take such action. YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 7 December 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 namely, the family of Nathaniel Phillips. ! 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. 13.10.2015 (Merrey Joanne Kearsley HM Area Coroner
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.
AG Rt Hon Alistair Burt MP Minister of State for Community and Social Care Department of H ealth Richmond House 79 Whitehalf London SWIA 2NS Tel: 020 7210 4850 Miss J. Kearsley, 10 DEC 2015 Area Coroner, Coroner’s Court 1 Mount Tabor Street Stockport SK1 3AG Thank you for your letter of 13 October 2015, following the inquest into the death of Nathaniel Phillips. I was sorry to hear of Mr Phillips’ death and wish to extend my condolences to his family. The main issue of concern in this case was raised by the family and GP. A diagnosis of brittle asthma is not one of the illnesses covered by the medical exemption certificate, despite the fact it is a life-threatening condition requiring medication. You noted that illnesses such as diabetes and epilepsy which require continuous medication are covered. The second concern is that the GP did not escalate Mr Phillips’ case or reassess his requirements and asthma control. The list of medical conditions for which patients are exempt from prescription charges was introduced in 1968, with the only addition to this list since then being cancer (in 2009). Ten conditions are included in this list. I believe, it would be unfair to sufferers from other diseases to consider asthma in isolation. However, extending the list to include all potentially life-threatening long term conditions would present a very significant cost to the NHS, which is already facing unprecedented budget pressures. There are, however, already a number of other routes to exemption from paying prescription charges, should the individual not qualify for a medical exemption. These include children under 16, people aged 60 or over and those in receipt of certain means tested benefits, leading to around 90% of all prescription items in England currently being dispensed without a prescription charge. Anyone on a low income, and not in receipt of benefits which provide automatic entitlement, can seek help under the NHS Low Income Scheme, which provides help with health costs on an income-related basis. The level of help available is based on a comparison between a person’s income and requirements at the time a claim is received, or at the time a charge was paid where a refund is claimed. To assist those who do have to pay, but who have a long term condition or on occasion may require a high number of prescribed items, Prescription Prepayment Certificates (PPCs) are available. The cost of annual and 3-month certificates is £104 and £29.10 respectively. There is no limit to the number of items that can be obtained through a PPC. The annual certificate benefits anyone needing more than 12 items a year, and the 3 month certificate benefits anyone needing more than 3 items in that 3 month period. PPCs can be obtained by calling 0845 850 0030 (local rates), online through the NHS Business Services Authority’s website (www.nhsbsa.nhs.uk) or by post. The application form FP95 is available from pharmacies. The second concern relates to the GP’s care and management of Mr Phillips. There appears to have been a lack of monitoring and re-assessment of Mr Phillips by the GP. It also appears that Mr Phillips presentations to the local emergency department following acute asthma attacks in January and February 2015, were not made known to his GP. If such information had been shared this should have initiated a review of Mr Phillips’ condition by the GP. Furthermore, it is not clear whether any attempt was made to advise Mr Phillips how he could obtain help to pay for his medication. I note that you did not send a copy of your Regulation 28 letter to the GP Practice concerned. I would be happy for you to send a copy of our reply to the GP Practice and trust that this will prompt them to review their patient care and prescribing practice in light of this case. More generally however, the General Medical Council (GMC) helps to protect patients and improve medical education and practice in the UK by setting standards for students and doctors. For example, doctors providing clinical care are expected to adhere to the following principles: Department of Health e prescribe drugs or treatment, including repeat prescriptions, only when you have adequate knowledge of the patient's health, and are satisfied that the drugs or treatment serve the patient's needs e provide effective treatments based on the best available evidence e check that the care or treatment you provide for each patient is compatible with any other treatments the patient is receiving, including (where possible) self- prescribed over-the-counter medications. Good practice in prescribing and managing medicines and devices (2013) provides more detailed advice to doctors on how to comply with the above principles when prescribing and managing medicines and medical devices, including appliances. A copy of this document is available on the GMC website. Within the guide is a section on Reviewing medicines and Repeat prescribing and prescribing with repeats which provides clear guidelines for doctors on the effective management of drugs for their patients (relevant excerpts are included at Annex A). I am grateful to you for bringing the circumstances of Mr Phillips’ death to my attention and hope that you find this reply helpful. (. Gs Nee te ALISTAIR BURT
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