Prevention of Future Deaths reports · 2015

Maureen Chatterley

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 report8 Oct 2015
Reference2015-0404
DeceasedMaureen Chatterley
CoronerAlan Walsh
Coroner areaManchester (West)
CategoryHospital Death (Clinical Procedures and medical management) related deaths
Sourcejudiciary.uk record · original PDF
Responses published1

The report

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

Responses

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.

Response from Bolton NHS Trust (PDF)
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

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