Prevention of Future Deaths reports · 2017
Regulation 28 report to prevent future deaths, reference 2017-0197, written 13 Jun 2017. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 13 Jun 2017 |
|---|---|
| Reference | 2017-0197 |
| Deceased | Craig Hamilton |
| Coroner | Nicola Mundy |
| Coroner area | South Yorkshire (East) |
| 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.
Ms N J Mundy Senior Coroner for South Yorkshire (East District) REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: The Practice Manager Manor Field Surgery, Braithwell Road, Maltby, Rotherham, S66 8JE CORONER lam Ms N J Mundy, Senior Coroner for South Yorkshire (East District) 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. http://www.legislation.gov.uk/ukpga/2009/25/schedule/5/paragraph/7 http://www. legislation.gov.uk/uksi/2013/1629/part/7/made INVESTIGATION and INQUEST On 14/12/2016 | commenced an investigation into the death of Craig Stuart Hamilton, 36 . The investigation concluded at the end of the inquest on 13 June 2017. The conclusion of the inquest was Prescribed drug related death. Craig Stuart Hamilton died at Maltby on 8 December 2016 after ingesting excess Tramadol medication in an attempt to relieve his chronic pain which unintentionally led to his death from acute tramadol toxicity CIRCUMSTANCES OF THE DEATH Mr Hamilton suffered a serious assault in 2009 leading to permanent and serious damage to his right leg. Part of the residual problems included chronic pain for which he received Tramadol from 2009 until the time of his death. It became clear from the evidence | heard that despite the prescribed rate (which was the maximum recommended by BNF for effective pain relief) in 2009, Mr Hamilton had effectively self medicated to the extent that he was taking almost double that dose on a regular basis from 2009 until the time of his death. Mr Hamilton died from Tramadol toxicity after taking excess amounts with the intention of controlling the pain sufficient that he could sleep during the night before working the next day. He did not take excess amounts with the intention of causing any self harm or ending his life. 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) Absence of clear procedures to manage patients who routinely access larger amounts of medication than actually prescribed. (2) Absence of clear procedures to monitor and manage patients who endeavour to obtain repeat prescriptions such that it takes them beyond the prescribed dosages. (3) Absence of clear procedures to fully explore drug regimes and alternative forms of pain management at annual medication reviews. (4) Consideration for improved systems for discussing with patients the implications of them attempting to exceed prescribed dosages and recording that such discussions have taken place. Coroner's Court and Office, Doncaster Crown Court, College Road, Doncaster, DN1 3HS Tel 01302 737135 | Fax 01302 736365 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and | believe you The Practice Manager, Manor Field Surgery 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 08 August 2017. |, 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 senta “ " ™ ; to the Chief Coroner and to the following Interested Persons: | 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. Dated 13 June 20 Signature Senior Coroner for South Yorkshire (East District) Coroner's Court and Office, Doncaster Crown Court, College Road, Doncaster, DN1 3HS Tel 01302 737135 | Fax 01302 736365
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.
Manor Field Surgery Maltby Services Centre, Braithwell Road, Maltby, Rotherham S66 8JE Tel: 01709 819376 Fax: 01709 819251 Website: manorfieldsurgery.co.uk 01 August 2017 Ms NJ Mundy Senior Coroner South Yorkshire (East District) Coroner’s Court and Office Crown Court College Road Doncaster DN1 3HS Dear Ms Mundy, Re: Craig Stuart HAMILTON (Deceased) DOB: 07.08.1980 DOD: 08.12.2016 Further to your letter and report in respect of the above named, please find our response and actions as below: We took immediate action on the afternoon of the inquest to identify the patients being prescribed tramadol and extended the search to other medicines with the potential for self- harm. All electronic prescriptions were changed to paper format and passed to the doctors for review before signing. All names of patients identified were passed to one of the partners to perform a review of the computer notes and make a recommendation. The inspection included the indication for the medicine * the recommended dose on the prescription * the recent historical issue pattern The recommended outcome was one of the following: * Immediate action to contact the patient i Request for early review * No change in current prescribing We have met several times as partners. We have sought advice from the Clinical Commissioning Group, particularly the Medicines Management Team. We asked the Drugs and Alcohol Team for advice and assistance in dealing with more difficult cases. Our local pharmacist was alerted to the problem and invited to provide information on prescriptions his team thought problematic. The issue has been escalated to a significant event through the national reporting system, 'STEIS (Executive Information System)’, via the local Clinical Commissioning Group. This report will be copied to them and contains extra information to allow them to complete their proforma. The search showed that 79 of our 90 patients taking tramadol were not abusing the drug. Action has been taken to limit the potential over-users by calling them in for early review. We have discovered that our procedures for issue and review of medication were not satisfactory. We have completed a thorough review of the medication ordering/ review procedure and found two problems that may have led to the death. e Our receptionists were skipping a computer dialog box reminding them of early issue of medication e Our doctors had insufficient time in the consultation for review of complex problems Since this incident our practice attitude has changed. We have changed our policy for repeat prescribing of all medication, not just tramadol. We enclose an amended ‘Repeat Prescribing Policy and Procedure’ and 'Acute Prescibing Protocol’. There are significant changes from our previous policy. I draw your attention to the specific instruction on the dialog box and to changes in the way the GP consultations are structured in time and process. The enclosed protocols have been examined by GP partners and practice manager. I am to explain to all staff in the practice, in protected time, the changes within 10 days. I hope the enhancements cover your Matters of Concern. Yours sincerely | GP Partner ence
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