Prevention of Future Deaths reports · 2015
Regulation 28 report to prevent future deaths, reference 2015-0404, written 8 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 | 8 Oct 2015 |
|---|---|
| Reference | 2015-0404 |
| Deceased | Maureen Chatterley |
| Coroner | Alan Walsh |
| Coroner area | Manchester (West) |
| Category | Hospital Death (Clinical Procedures and medical management) 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. Dr Jackie Bene, Chief Executive Trust Headquarters, Royal Bolton Hospital, Minerva Road, Farnworth, Bolton, BL4 0JR CORONER Iam Alan Peter Walsh, Area Coroner for the Coroner Area of Manchester West 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 7" January 2015 I commenced an Investigation into the death of Maureen Chatterley (formerly known as Maureen Hinckley), 68 years, born 15% September 1946. The medical cause of death was 1a) Bronchopneumonia, 1b) Chronic Obstructive Pulmonary Disease, 2) Coronary Artery Atherosclerosis and infected right hip following fracture of neck of right femur. The conclusion of the Inquest was Maureen Chatterley died as a consequence of naturally occuring disease exacerbated by injuries sustained in an accidental fall and recognised complications arising from the treatment of her injuries. CIRCUMSTANCES OF THE DEATH 1. Maureen Chatterley died at the Royal Bolton Hospital, Minerva Road, Farnworth, Bolton on the 24" December 2014. . On the 27" August 2014 Mrs Chatterley had a fall at her home address at sustaining a fracture of the neck of femur of the right hip. She was taken to the Royal Bolton Hospital, Bolton and on the 29" August 2014 she had surgery to repair the fracture. Mrs Chatterley was discharged from the hospital on the 1* September 2014 but she was re admitted to the hospital on the 4" October 2014 with a dislocated prosthesis of the right hip. The hip was manipulated to reduce the dislocation and Mrs Chatterley was discharged from the hospital on the 6" October 2014. On the 9" October 2014 Mrs Chatterley suffered a further dislocation of the hip and she was admitted to the Royal Bolton Hospital where she had surgery on the 9" October 2014 and the 13 October 2014 when the prosthesis was removed. Mrs Chatterley had further surgical procedures on the 4" November 2014 and the 18 November 2014 to explore the hip and to carry out wash outs of puss and a haematoma. . From the 9" October 2014 until the 24" December 2014, when Mrs Chatterley died, she was treated with antibiotics and other medications including Loperamide for irritable bowel and Lorazepam for anxiety and agitation. The dose of Lorazepam, which was commenced in December 2014, was prescribed as “PRN dose of 0.5mg to a maximum 1mg in 24 hours”, » On the 14 December 2014 the family was concerned that 2 x img of lorazepam was given as a single dose and the family informed a Doctor and the nursing staff of their concerns in relation to the excess dose. The medication chart did not indicate that an excess dose of Lorazepam had been administered and the medication chart showed that the correct dose had been administered. However there was no investigation in relation to the family’s concerns and the number of Lorazepam tablets in Mrs Chatterley’s medication drawer was not checked at the time . On the 14 October 2014 Mrs Chatterley was transferred from Ward G4 to Ward G3, which is the Trauma Stabilisation Unit. Evidence was heard at the Inquest from a consultant nurse and from the ward manager in relation to medication prescribed to Mrs Chatterley whilst she was treated on Ward G3. The evidence referred to the fact that medications would be prescribed by a doctor and obtained either from the pharmacy in the hospital or from a stock of medication kept in a cupboard on the ward. The medication would be requested and obtained by the by the nursing staff and the medication would be placed in a medication drawer allocated to the patient. The control of medication depended upon whether the medication was a controlled drug or a non-controlled drug. In relation to non-controlled drugs, which included Lorazepam, a stock was kept in a cupboard on the ward and a nurse would obtain the medication from the stock in the cupboard and place the medication in the allocated medication drawer. The number of tablets placed in the allocated medication drawer are not counted, either individually or by the box, when they are placed in the medication drawer and, on occasions, an unidentified number of tablets from opened boxes are placed in the drawer. When Mrs Chatterley was prescribed Lorazepam the nurse obtained the Lorazepam tablets from the cupboard on the ward and placed an unknown number of tablets into the medication drawer allocated to Mrs Chatterley. However there was no record of the number of tablets laced in the medication drawer allocated to Mrs Chatterley and there was no stock record or control of the tablets remaining in the cupboard on the ward. Accordingly the evidence confirmed that there was no record of the number of tablets in the medication drawer nor the cupboard on the ward at any point in time. . The ward manager gave evidence that there may be over 100 medications supplied to patients on Ward G3 and it would be impossible to keep a record of the number of tablets either in the medication drawers or the cupboard on the ward. . The conclusions of the Inquest accepted that any excess dose of Lorazepam tablets did not play a part in the cause of death but it was accepted that, although there was no direct evidence of the administration of an excess dose, the concerns of the family had not been investigated and the administration of an excess dose of the medication could not be excluded. RONER‘ 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 There was no investigation by the hospital in relation to the concerns expressed by the family in relation to the administration of an excess dose of Lorazepam. There was no record of the stock of medication in relation to non-controlled drugs in the medication drawer allocated to a patient nor in and the medication cupboard on the ward. Accordingly medication could be removed from the medication cupboard on the ward and used either for an elicit purpose or excess dosage without any knowledge or record with reference to stock control. Evidence was given at the Inquest that the pharmacist checked medications on the ward on a daily basis but there was no check or record of the number of medications or the number of tablets in the allocated medication drawers or the cupboard on ward, particularly between the daily inspections by the pharmacist. 2. I request you to consider the above concerns and try carry out a review with regard to the following: i. The procedures in relation to the supply, security and safe keeping of medication on wards at the Royal Bolton Hospital. Stock control and a record of medications both in the medication drawers allocated to individual patients and in cupboards on wards at the Royal Bolton Hospital to enable the medications and the quantities of medications to be identified and verified, both in the medication drawers and in the cupboards on the ward, at any point in time. The evidence raised concerns that there is a risk that future deaths will occur unless action is taken to review the above issues. ACTION SHOULD BE TAKEN In my opinion urgent action should be taken to prevent future deaths and I believe you and your organisation 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 2% December 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. COPIES and PUBLICATION I have sent a copy of my report to the Chief Coroner and to the following Interested Persons 1. [RY vrs chatteriey’s Husband 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. Signed WA Mr Alan P Walsh Dated 8" October 2015
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.
Telephone: (01204) 390390 ext 5912 Our Ref: 1.001893 Bolton Your Ref: APW/CAH/3875-2014 NHS Foundation Trust Bolton NHS Foundation Trust * Minerva Road Farnworth Bolton BL4 OJR 25" November 2015 www.boltonft.nhs.uk Mr Alan P Walsh HM Area Coroner West District Paderborn House, Civic Centre BOLTON BLi 1JW Dear Mr Walsh Re: Maureen Chatterley~ Deceased Re: Regulation 28 Report to Prevent Future Deaths 1 am writing in response to your Regulation 28 Report to Prevent Future Deaths, issued following the Inquest into the death of Maureen Chatterley held on 29 September 2015. May | take this opportunity to extend my sincere condolences to the family of Mrs Chatterley for their loss. On receipt of the Regulation 28, | requested that the Chief Pharmacist and Medicines Safety Group review the matters detailed in your Report and | am now in a position to respond to your concerns outlined in Section 5 (1) and (2) of the Report as follows:- The Medicines Safety Group was created in 2013 with the purpose to develop, implement and maintain a medication governance strategy and work plan within Bolton Foundation Trust around the safe and effective use and management of medicines. The full terms of reference for this group are attached for your information. The procedures for security and safe keeping of medicines on wards is regulated by the standards set out in the Safe and Secure Handling of Medicines (2005), formally known as the Duthie Report (http:/Avww.dhsspsni.gov.uk/the-safe-and-secure-handling-of-medicines. pdf). All clinical areas are audited quarterly, by pharmacy staff, against these standards and the results are discussed with the ward managers. In addition to this the Medicines Safety Group has recently introduced additional measures to audit the security of medicines by introducing the NHS Protects Medicines Security Ward/Department checklist. These are completed by ward staff and collated for each division and the results and action plans discussed at the Medicines Safety Group. Copies of both audit forms have been included for information. Local processes already in place that mitigate the risks related to medicines storage include the ordering of stock medicines by pharmacy staff for individual clinical areas. This completed, as a minimum, weekly but is based on demand. ’ While Safe and Secure Handling of Medicines (2005) deals in the main with medicines storage, the legal requirements for prescribing, administration and storage are regulated by the Medicines Act 1968 and the Misuse of Drugs Regulation 2001. These key pieces of tegisiation along with documents such as Safe and Secure Handling of Medicines (2005) inform the development of our Trust medicines policy (attached). As you will be aware, the Misuse of Drug Regulations 2001, regulate the activities for certain medicines considered to be potentially harmful or dangerous and these are referred to as controlled drugs. Under the various Schedules within the regulations only those medicines in Schedules 1 or 2 e.g. morphine are subject to the requirement of running balances. The Trust completes quarterly controlled drug audits against the regulations. Many Trusts, including Bolton NHS Foundation Trust have introduced additional controls for medicines where local intelligence would suggest further restrictions beyond those required of the Medicines Act 1968 should be introduced. This is often referred to as restricted drugs. Legally they can’t be referred to as controlled drugs but restrictions on their use are similar to that imposed by the Misuse of Drugs Regulations 2001. The Medicines Safety Group has considered, in light of your concerns raised, the inclusion of Lorazepam as a restricted drug. However we feel adequate controls are in place, as outlined above, that do not warrant Lorazepam’s inclusion to a restricted list. This decision has been taken in consideration of the restrictions balanced against the potential for missed doses, delays in administration and increase in nursing time in medicines administration. To facilitate the flow of patients through the organisation, Bolton NHS Foundation Trust has in place a one stop dispensing process. This not only encourages the use of patients own drugs during admission but also encourages the dispensing of medicines to patients for individual use, therefore reducing the use of stock medicines. The process in pharmacy provides a permanent record in the patient’s shared electronic record of the date of dispensing, the quantity supplied and a date to review the stock levels and need for re-supply before the supply is exhausted. Where a patient brings their own medicines into the Trust, these are assessed for suitability of use (Appendix 16, Medicines Policy). The quantity brought in is recorded by pharmacy staff according to local policy DOP30b- Procedure for ward visit. The above outlines the measures in place that the Medicines Safety Group believes will mitigate the matters of concern highlighted in your report, however in addition to the above the Group have also agreed the following actions and timescales: Action Target Date To be actioned by introduce new Wardex, which Dec 2015 Medicines Safety Group includes a section for pharmacists to record reviews of the wardex. This includes the clinical review and supply of medicines Develop and implement a local Feb 2016 Medicines Safety Group endorsement policy by pharmacy staff of the Wardex, to include supply and quantity details. Safe and Secure Handling of Dec 2015 Medicines Safety Group Medicines Audits (Duthie) to be presented to Medicines Safety Group for discussion and agreement of action plans. | am confident that the Trust has the necessary systems in place to ensure that medication which is kept on wards is stored safely and securely and that the Trust is able to verify at any point in time the medication stored in both stock cupboards and patient's medication drawers. 1 do hope that my response has provided you with the assurance that you and the family are looking for. If you need any further information, or if | can be of any further assistarice please do not hesitate to contact me. Yours sincerely Hibs foe | Dr Jackie Bene Chief Executive
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.