Prevention of Future Deaths reports · 2016
Regulation 28 report to prevent future deaths, reference 2016-0249, written 14 Jul 2016. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 14 Jul 2016 |
|---|---|
| Reference | 2016-0249 |
| Deceased | Fred Whittaker |
| Coroner | Andrew Bridgman |
| 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 (1) REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: 1. Fo Practice Manager, Heaton Moor Medical Centre, 32 Heaton Moor Road, Stockport SK4 4NX. 2. R Simon Stevens, CEO NHS England, NHS England, PO Box 16738, Redditch B9 9PS 3. Medical Director NHS England Greater Manchester, 3 Piccadilly Place, London Road, Manchester M1 3BN 4 CORONER Andrew Bridgman, Assistant Coroner, for the coroner area of Manchester South. 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. INVESTIGATION and INQUEST On 2™ November 2015 an investigation was commenced into the death of Fred Whittaker who died at his home address on 25" October 2015. The investigation concluded with an Inquest held on 3" July 2016. The conclusion of the Inquest was: Narrative: Mr Whittaker died from the combined effects of a developing bronchopneumonia and the consumption of excessive amounts of codeine, methadone and alcohol. Medical cause of death la Bronchopneumonia ; and combined Codeine, Methadone and Alcohol Toxicity il Cirrhosis of the Liver due to Alcoholism and Hepatitis C; Type 2 Diabetes Mellitus; Hypertensive Heart Disease | CIRCUMSTANCES OF THE DEATH Mr Whittaker was a 37 year old gentleman diagnosed with schizophrenia who was also known to abuse drugs, namely benzodiazepines, codeine and alcohol. In the early hours of the 24th October 2015 Mr Whittaker summoned an ambulance as he was having chest pains and feeling drowsy. He was taken to Accident and Emergency at Stepping Hill Hospital where he first admitted taking two codeine tablets with a large amount of alcohol. He later admitted to having taken four pots of methadone. Naloxone was administered by infusion and his GCS by 8.40am had returned to 15. At about 9.30am Mr Whittaker removed his cannula for the Naloxone infusion. At 11.01 am Mr Whittaker self-discharged and went home. He was seen by a support worker at about 12.30pm; he was noted to be well and did not appear to be under the influence of drugs or alcohol. He was given his prescribed medication for that day. On the morning of the 25th October 2015 Mr Whittaker was found dead in his bed at his flat. CORONER’S CONCERNS An important issue in the Inquest was the continued prescription of Clonazepam by the Heaton Moor Medical Centre despite the written request on 17” August 2015, from Mr Whittaker’s treating psychiatrist, that this medication be stopped. The evidence given to me oy a partner at the Heaton Moor Medical Centre, suggests that although the prescription was stopped it was started again in error. GE ecvisedt a) On receipt of request the drug was moved from the Repeat Prescription list to the Past Prescription list, without any reference in the records of the reason as to why the Clonazepam was being stopped. b) On or about the 49" August 2015 the pharmacy which administered Mr Whittaker’s medications requested a repeat prescription. c) It was likely that upon receiving that request Clonazepam was simply moved back on to the repeat prescription by one of the doctors at the Practice on being advised by an administrator of the Pharmacy’s request. This is clearly an unacceptable error. | accept that, on this occasion, this error played no part in Mr Whittaker’s demise but it is not difficult to imagine a completely different set of circumstances where such an error would give rise to a risk of death. evidence was that there were no standard directions as to how to manage this as a situation and that other practices may adopt the same simple policy of transferring the drug from one list to another. 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. — 4. That Heaton Moor Medical Centre does not have a mechanism whereby the reasons or requests or decisions that a patient is no longer to be prescribed a particular drug are recorded in the clinical records. 2. That this poor practice may not be limited to Heaton Moor Medical Centre and is replicated in many GP practices in the Northwest and indeed, nationally. ACTION SHOULD BE TAKEN In my opinion action should be taken by Heaton Moor Medical Centre to develop a system such the risk of the inadvertent re-prescription of discontinued medications is reduced to its minimum or negated. In my opinion NHS England should draw fo the attention of all GP practices this potential for the inadvertent re-prescription of discontinued medications and to take steps to ensure the risks are reduced to its minimum or negated. YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 8” September 2016. 1, 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. | 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. 14™ July 2016 Andrew Bridgman Assistant 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.
NHS England Professor Sir Bruce Keogh National Medical Director Skipton House 80 London Road Andrew Bridgman SE1 6LH Assistant Coroner for Manchester South Coroner Court 1 Mount Tabor Street Stockport Sth September 2016 SK1 3AG Dear Mr Bridgman, RE: Fred Whittaker —- NHS England Regulation 28 Report Response Thank you for your letter dated 14 July 2016 regarding your Regulation 28 Report following your investigation and inquest into the death of Mr Fred Whittaker. On behalf of NHS England | would like to express our sympathy to Mr Whittaker’s family. NHS England is a single national organisation and FY Medical Director for Greater Manchester is professionally accountable to me. This letter is NHS England’s single response on behalf of both of us and I trust you will find this acceptable. You have raised the following concern for NHS England to respond fo: “NHS England should draw attention of ali GP practices this potential for the inadvertent re-prescription of discontinued medications and to take steps to ensure the risks are reduced to its minimum or negated.” All GP practices in England have electronic clinical systems to support them in the delivery of their care of patients. Within the patient record there is the ability to record both acute (i.e. one off) and regular ‘repeat’ prescriptions. When a repeat prescription is generated, the reason or diagnosis for the medication should be recorded. Similarly, when a repeat medication is stopped, the reason for stopping the medication should be recorded in the clinical records. In the guidance published by the Department of Health, Responsibility for prescribing between hospitals and GPs EL (91) 127, 1991 (enclosed) makes it clear that the legal responsibility for prescribing lies with the doctor who signs the prescription. The issue of any prescription and the subsequent doctor's signature is to assure the dispensing pharmacist that the doctor considers the medication to be appropriate and necessary to treat that patient, giving due regard to dose, High quality care for all, now and for future generations strength, duration, formulation and interactions with other medication or with the patient's physiology. In this instance the prescribing GP should have been alerted to the fact the medication requested by the pharmacy had in fact been stopped by the patient's consultant. | have been assured by my colleague F Medical Director NHS England, that the practice and GPs involved have undertaken an appropriate review, are planning to undertake a thorough significant event analysis and have put into place appropriate measures to prevent a recurrence of a similar event. a ::; informed me that he will raise this regulation 28 report and our response at the Quality Surveillance Group that has oversight of the quality of health and social care in Greater Manchester. He is writing to all GPs in Greater Manchester to share learning from this tragic event and to remind them of their responsibilities when prescribing for patients, especially when making changes, stopping and starting medicines. He is also writing to the medicine management teams of the Greater Manchester Clinical Commissioning Groups to ask them to provide relevant advice and support to practices. Additionally, NHS England will share this learning and best practice further with GPs. | trust this response addresses the concern as detailed in your report and thank you for bring this important matter to my attention. Yours sincerely, ve Professor Sir Bruce Keogh KBE, MD, DSc, FRCS, FRCP National Medical Director NHS England High quality care for all, now and for future generations
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