Prevention of Future Deaths reports · 2017
Regulation 28 report to prevent future deaths, reference 2017-0324, written 1 Aug 2017. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 1 Aug 2017 |
|---|---|
| Reference | 2017-0324 |
| Deceased | Hayley Sheehan |
| Coroner | Anna Crawford |
| Coroner area | Surrey |
| 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.
IN_ THE SURREY CORONER’S COURT IN THE MATTER OF: The Inquest Touching the Death of Hayley Denise Sheehan A Regulation 28 Report - Action to Prevent Future Deaths 1 | THIS REPORT 1S BEING SENT TO: a 2. BE © vactice and Business Manager The Moat House Surgery Worsted Green Merstham Surrey RHI 3PN 2 | CORONER Ms Anna Crawford, HM Assistant Coroner for Surrey 3 | CORONER’S LEGAL POWERS I make this report under paragraph 7(1) of Schedule 5 to The Coroners and Justice Act 2009. 4 | INVESTIGATION and INQUEST An investigation was commenced on 28 November 2016 and the inquest into the death of Hayley Denise Sheehan was opened on 9 January 2017. Tt was resumed and concluded on 26 July 2017, The medical cause of death was found to have been: la, Tramadol toxicity. The inquest concluded with a short form conclusion of ‘Accident’. 5 | CIRCUMSTANCES OF THE DEATH Mrs Sheehan suffered from fibromyalgia. She was a patient at the Moat House Surgery in Merstham, where she received a repeat prescription for 112 200mg slow release Tramadol tablets every two months, to be taken twice a day. | L On 22 November 2016 Mrs Sheehan collapsed and died at her home ad- dress, having unintentionally overdosed on her prescription Tramadol. The medical cause of her death was found to be 1a. Tramadol toxicity. the Forensic Toxicologist, gave evidence that the levels of Tramadol present in Mrs Sheehan’s system were consistent either with her having taken 25 tablets shortly before her death or, alternatively, with her having taken her prescribed dose more than twice a day over a more prolonged period of time. r | a GP partner at the Moat House Surgery, told the court that during the period from 9 February to 7 November 2016 Mrs Sheehan had regularly requested her repeat prescription for Tramadol early and. as a result she was able to obtain a total of 896 tablets as opposed to the 560 tablets which were envisaged by her repeat prescription, an excess of 336 tablets, With regards to the last prescription before her death, Mrs Sheehan received a prescription of 112 tablets on 7 November 2016, despite her next prescription not being due until the beginning of De- cember 2016, P| told the court that patients’ requests for repeat prescriptions are dealt with by prescription administrators who receive the request and then prepare the prescription for a GP to sign, The system in place is such that in the event that a patient requests a prescription too early, the administrator should draw the request to the attention of a GP, who then makes a decision with regards to whether or not to authorise it. Having considered the evidence, the court found that Mrs Sheehan’s requests for early prescriptions had not been identified, or acted upon, during the course of 2016, and that as a result she had been able to ob- tain a significant amount of excess medication. HB oc the court that following Mrs Sheehan's death the prescrip- tion administrators have been trained to highlight early requests for re- peat prescriptions to GPs. He also said that new procedures have been introduced in respect of the prescription of Tramadol, and that in par- ticular the Surgery now only prescribes it as an acute prescription, as opposed to a repeat prescription. a: the court that the Sur- gery was considering introducing similar measures in respect of other controlled medicines. CORONER'S CONCERNS The MATTERS OF CONCERN are: - The procedure for issuing repeat prescriptions relies heavily up- on the prescription administrators identifying and flagging early requests to GPs, As far as HE was aware, the software used by the surgery does not automatically identify early prescription requests, Consideration should be given to introducing more safeguards to en- sure that early requests for repeat prescriptions are identified and drawn to the attention of a GP. This should include giving considera- tion to whether the relevant software can be adapted to automatically identify early prescription requests, ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I be- lieve that the people listed in paragraph one above have the power to take such action, YOUR RESPONSE You are under a duty to respond to this report within 56 days of its date; I may extend that period on request, Your response must contain details of action taken or proposed to be taken, setting out the timetable for such action, Otherwise you must ex- plain why no action is proposed, COPIES Thave sent a copy of this report to the following: 7 2, a 4, The Chief Coroner In addition to this report, I am 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, at the time of your response, about the release or the publication of your response by the Chief Coro- ner. 10 | Signed: ANNA CRAWEORD DATED this Ist day of August 2017
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.
THE MOAT HOUSE SURGERY WORSTED GREEN MERSTHAM SURREY RH1 3PN Telephone: 01737 642207 Fax: 01737 642209 30"" August 2018 Anna Crawford HM Assistant Coroner HM Coroner’s Court Station Approach Woking Surrey GU22 7AP Dear Ms Crawford, Re: Mrs Hayley Denise SHEEHAN (Deceased) Regulation 28 Report to Prevent Future Deaths Further to your letter dated 1° August regarding Regulation 28 Report to Prevent Future Deaths and that ‘consideration should be given to introducing more safeguards to ensure that early requests for repeat prescriptions are identified and drawn to the attention of a GP. This should include giving consideration to whether the relevant software can be adapted to automatically identify early prescription requests.’ A meeting was held at the Moat House Surgery attended by the GP Partners, Practice Manager, IT Manager and the lead clinical administrator on 17" August 2017. Following discussion at the meeting an e-mail was sent to EMIS Health, the provider of our clinical software system EMIS Web, requesting changes to the EMIS prescribing process, so that early prescription requests are ‘flagged up’. | enclose copies of the correspondence. In the meantime, our IT Manager has developed a pop-up box within patients’ notes which alerts the issuer of a prescription to the fact that a previous prescription had been issued less than 30 days previously. The pop-up box can be configured to flag an early request for all drugs, a particular drug, or drug ingredient. It is currently configured to use a predefined list of products with controlled drug ingredients. The ‘safety net’ feature added to the EMIS Web system is a template called ‘Controlled Drug Monitoring’, which will include all patients who are on Tramadol and opioid-based medication and will be grouped according to their registered GP. A search will be carried out on the 1° Monday of every month and the GPs concerned will be advised to carry out a medication a j _ _ _ Email: support@themoathousesurgery,co.uk review. The search will list all opioid products and Tramadol Hydrochloride products issued in the last month where a medication review was not performed in the last three months. GP’s can use the template to find out how many medications have been issued to a particular patient and will set a date for the next medication review. The Clinical Administrators can see the pop-up warning and will also be able to see the last medication review date in the Medication screen and will be able to:- e Decline the request © Bring to the attention of the relevant GP that medications are being requested too early © Bring to the attention of the relevant GP if there are concerns that patients may be stockpiling medication or using them in excess of the prescribed dose. We are addressing the concerns raised by you, thereby providing improved safeguarding for our patients against any further serious incidents resulting from accidental overdose of medication. Yours sincerely, GP Partner Moat House Surgery Enc.
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