Prevention of Future Deaths reports · 2016
Regulation 28 report to prevent future deaths, reference 2016-0330, written 15 Sep 2016. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 15 Sep 2016 |
|---|---|
| Reference | 2016-0330 |
| Deceased | Richard Breatnach |
| Coroner | Veronia Hamilton-Deeley |
| Coroner area | Brighton and Hove |
| Category | Alcohol, drug and medication 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.
VERONICA HAMILTON-DEELEY, LL.B. THE CORONER’S OFFICE Her Majesty’s Senior Coroner WOODVALE, LEWES ROAD for the City of Brighton & Hove BRIGHTON BN2 3QB Assistant Coroners CATHARINE PALMER LL.B (HONS) KAREN HENDERSON, BSC,BM,MRCPI,FRC. . GILVA D.J.TISSHAW, BA(LAW)HONS Telephone: Brighton (01273) 292046 Fax: Brighton (01273) 292047 a CORONERS SOCIETY OF ENGLAND AND WALES ANNEX A REGULATION 28: REPORT TO PREVENT FUTURE DEATHS (1) NOTE: This form is to be used after an inquest. REPORT IS BEING SENT TO: 1. EE 41 8 Healthcare Limited, v Jame 4 - 1100, Prague 1. Czech Republic. 2. TER HR Healthcare Limited, The Office, Britannia Way, Bolton. Lancashire. BL2 2HH. 3. Professor Sir Bruce Keogh, KBE, MD, DSc, FRCS, FRCP, National Medical Director, NHS England, Skipton House, 80 London Road, SE1 6LH. CORONER lam Veronica HAMILTON-DEELEY, Senior Coroner, for the City of Brighton and Hove 2 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 24" August, 2016 | commenced an investigation into the death of Philip Richard David BREATNACH otherwise Richard BREATNACH. The investigation concluded at the end of the inquest on 24" August, 2016. The conclusion of the inquest was MISADVENTURE (DEPENDENCE ON DRUGS) VERONICA HAMILTON-DEELEY, LL.B. Her Majesty’s Senior Coroner for the City of Brighton & Hove THE CORONER’S OFFICE WOODVALE, LEWES ROAD BRIGHTON BN2 3QB Assistant Coroners CATHARINE PALMER LL.B (HONS) KAREN HENDERSON, BSC,BM,MRCPI,FRC. . GILVA D.J.TISSHAW, BA(LA W)HONS Telephone: Brighton (01273) 292046 Fax: Brighton (01273) 292047 4 CIRCUMSTANCES OF THE DEATH See Record of Inquest 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) Mr Breatnach (and anybody else) is able to apply online for medications (2) That applying online, if the application form is not thoroughly checked , allows the applicant to lie or give false or misleading answers to critical questions which is what Mr Breatnach did. (3) There was no evidence that the prescriber made any effort to contact Mr Breatnach’s GP to find out if the answers that he gave were true. (4) Prescribing Dihydrocodeine, a potentially addictive drug, used for the treatment of moderate to severe pain to a patient who the prescriber has never seen appears to fly in the face of good prescribing practice. (5) The amount of Dihydrocodeine prescribed appears to be excessive. (6) understand from the evidence that | heard at the Inquest that Dihydrocodeine should not be prescribed for migraine which is the reason Mr Breatnach gave for asking for this medication. (7) The instructions were that the Dihydrocodeine should be taken every four to six hours as required. The evidence at the Inquest was that taking Dihydrocodeine in this way, potentially suggesting that eight tablets could or should be taken every twenty four hours until the whole of the one hundred and twenty six tablets given are used up is | heard not the way Dihydrocodeine should be prescribed. (8) Prescribing this number of tablets would therefore seem to be completely inappropriate and fails to understand that medications such as Dihydrocodeine can be used as currency. The medication came in three packets — one containing one hundred tablets and the other two containing twenty eight tablets each. The two packets containing twenty eight tablets VERONICA HAMILTON-DEELEY, LL.B. Her Majesty’s Senior Coroner for the City of Brighton & Hove THE CORONER'S OFFICE WOODVALE, LEWES ROAD BRIGHTON BN2 30B Assistant Coroners CATHARINE PALMER LL.B (HONS) _ KAREN HENDERSON, BSC,BM,MRCPI,FRC. - GILVA D.J.TISSHAW, BA(LAW)HONS Telephone: Brighton (01273) 292046 Fax: Brighton (01273) 292047 each were never found and this raises the possibility that Mr Breatnach was able to sell them, although | have no evidence that he did. (9) This way of prescribing completely undermines the diligent and careful GP’s efforts to control this man’s medication over use. ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and | 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 2016. |, 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. 2. 3. Secretary of State for Health, Department of Health 4. Simon Stevens, Chief Executive NHS England 5. National Patient Safety Agency | have also sent it to:- 6. a General Pharmaceutical Council 7. Royal Pharmaceutical Society 8. EE General Medical Council 9. ER Sussex Police (OEE GP Brighton Who may find it useful or of interest. THE CORONER’S OFFICE WOODVALE, LEWES ROAD BRIGHTON BN2 3QB VERONICA HAMILTON-DEELEY, LL.B. Her Majesty’s Senior Coroner for the City of Brighton & Hove Telephone: Brighton (01273) 292046 Fax: Brighton (01273) 292047 Assistant Coroners CATHARINE PALMER LL.B (HONS) KAREN HENDERSON, BSC,BM,MRCPLFRC. _ GILVA D.J.TISSHAW, BA(LAW)HONS | 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. Date: 15' September 2016 SIGNED ev: [ofeaaue. ON- elo Veronica HAMIL Senior Coroner Brighton and Ho
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.
RECEIVED
28 NOV 2016
Veronica Hamilton-Deeley, LL.B
England
Professor Sir Bruce Keogh
National Medical Director
Skipton House
80 London Road
SE1 6LH
Senior Coroner for City of Brighton&
Hove
The Coroner's Office
Woodvale
Lewes Road
Brighton
BN2 3QB 2utn November 2016
Your ref: as
Dear Ms Hamilton-Deeley,
Thank you for your letter of 15" September 2016 and the réport written under
Paragraph 7, Schedule 5 of the Coroners and Justice Act 2009 and Regulations
28 and 29 of the Coroner's (investigations) Regulations 2013, setting out the sad
circumstances surrounding the death of Mr Breatnach.
| note there are nine express concerns set out by the Coroner in the Regulation
28 report which generally concern the prescribing of drugs on-line.
it may be helpful if | explain that NHS England is formally known as the NHS
Commissioning Board in legislation (Section 9 Health & Social Care Act 2012
amending Sections 1G & 1H of the NHS Act 2006). The Board’s functions and
duties are set out in that legislation too and include a duty in respect of
commissioning arrangements for NHS services. These include commissioning
primary care services (including general practice and pharmacy), managing
performer's lists and maintaining the pharmaceutical list. We also have
responsibility for ensuring that primary care contractors work within the terms of
their contract, or for pharmacies under their Terms of Service which are outlined
in the NHS (Pharmaceutical and Local Pharmaceutical Services) Regulations
2013) and can take action such as issuing breach notices and requiring action or
withholding payments in certain circumstances.
As noted in my letter of 27th July 2016, NHS England has, what may be termed,
a “systems oversight” role for the safe use of controlled drugs (including
dihydrocodeine) under the Controlled Drugs (Supervision and Management of
Use) Regulations 2013. We raised the issues arising from this case at the Care
Quality Commission National Controlled Drugs Group on 14th June 2016 and
hosted a multiagency meeting to discuss these issues further on 2nd November
2016. Representatives from the Police Force, Care Quality Commission,
Department of Health, General Medical Council, General Pharmaceutical
Council, Medicines and Healthcare products Regulatory Agency, NHS England,
NHS Improvement and the British Medical Association General Practitioners
High quality care for all, now and for future generations
Committee attended (a full list of attendees is set out in Annex 1 and a brief
explanation of the role of each of the organisation to assist the Coroner in
understanding the nature and extent of various Regulatory bodies involved in this
issue.
The group agreed to work together to assimilate current regulatory and
professional guidance into one place so there is greater clarity regarding good
practice in respect of online prescribing and supply of medicines giving particular
guidance on medicines such as controlled drugs and antibiotics.
Agencies also shared intelligence on this case. Regulators agreed to work
together further to look at protecting vulnerable patients in future.
NHS England will use this learning to inform its Digital Strategy. We will also
include advice to General Practitioners about Special Patient Notes, which are
used within the integrated urgent care software so alerts can be set up for NHS
111 call handlers and out of hours general practitioners when they access a
particular patient record as part of the Pharmacy Urgent Medicines Supply
service being introduced from ist December 2016.
We will continue to discuss the Coroner's concerns and endeavour to develop
strategies in partnership with other responsible agencies aimed at preventing
future deaths.
Yours sincerely, { -)
4
de Me
Professor Sir Bruce Keogh KBE, MD, DSc, FRCS, FRCP
National Medical Director
NHS England
High quality care for all, now and for future generations
See every Prevention of Future Deaths report matching Alcohol, drug and medication 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.