Prevention of Future Deaths reports · 2017
Regulation 28 report to prevent future deaths, reference 2017-0349, written 30 Nov 2017. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 30 Nov 2017 |
|---|---|
| Reference | 2017-0349 |
| Deceased | Penelope Benton |
| Coroner | Zafar Siddique |
| Coroner area | Black Country |
| Category | Mental Health related deaths · Suicide (from 2015) |
| Organisation named | Dudley and Walsall Mental Health Partnership NHS Trust |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
REGULATION 28: REPORT TO PREVENT FUTURE DEATHS REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: 1. Dudley and Walsall mental Health Partnership NHS Trust 1 CORONER I am Zafar Siddique, Senior Coroner, for the coroner area of the Black Country. 2 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. 3 INVESTIGATION and INQUEST On the 20 September 2017, I commenced an investigation into the death of the late Ms Penelope Benton. The investigation concluded at the end of the inquest on 31 October 2017. The conclusion of the inquest was a short narrative conclusion of suicide. The cause of death was: 1a Tramadol Overdose 4 CIRCUMSTANCES OF THE DEATH i) Ms Benton had a complex medical history including diagnosed paranoid schizophrenia and also a history of self-harm including drugs overdoses. She also had a stoma fitted following an obstruction to her bowel. This had caused significant pain over a number of years. ii) On the 22 September 2016 she was admitted to Bushey Field Hospital after a relapse and sectioned under S3 Mental Health Act. She disclosed to her care co-coordinator on the 26 September 2016 that she had taken an overdose of 60 Tramadol tablets and that she had had enough of her pain and wanted it to go away. iii) After making improvement she was discharged with support in the community on the 18 October 2016. The discharge note did not record any details of the Tramadol overdose and the GP continued to give her Tramadol medication for pain relief. iv) On the 12 July 2017, Ms Benton took a significant quantity of Tramadol tablets (40.4mg/L) and fatalities have been associated with concentrations of greater than 6 mg/L. v) Sadly, she was pronounced deceased on the same day and the cause of death was later confirmed as Tramadol overdose. 1 [IL1: PROTECT] 5 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. Evidence emerged during the inquest that the General Practitioner wasn’t made aware of the previous tramadol overdose on the discharge letter from Hospital. 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you have the power to take such action. 1. You may wish to consider urgently reviewing the discharge process and information shared with primary health services on discharge of patients. 7 YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 29 January 2018. 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. 8 COPIES and PUBLICATION I have sent a copy of my report to the Chief Coroner and to the following Interested Persons; Family. 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. 9 30 November2017 Mr Zafar Siddique Senior Coroner Black Country Area 2 [IL1: PROTECT]
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.
2nd Floor Trafalgar House 47-49 King Street Dudley DY2 8PS Tel: 01384 324524 Email: 19/01/2018 2016 Mr Z Siddique HM Senior Coroner Black Country Coroner’s Court Jack Judge House Halesowen Street Oldbury West Midlands B69 2AJ Dear Mr Siddique Ref: Penelope Benton Regulation 28 Ruling – Dudley and Walsall Mental Health Partnership NHS Trust Response I am writing on behalf of Dudley and Walsall Mental Health Partnership NHS Trust in response to the recent HM Coroners Regulation 28 Report issued to the Trust, following the recent coronial inquest into the death of Ms Penelope Benton. I would, first of all, like to pass on our sincere condolences and state that the Trust is fully committed to providing excellent Mental Health care to the service users of Dudley and Walsall in a way which is safe and effective for patients and their families. The Trust acknowledges the fact that in this instance the General Practitioner was not made aware of the previous tramadol overdose in the discharge letter from hospital. The Trust has agreed standards in relation to ensuring good communication with General Practitioners which includes the standards expected when writing discharge letters. A copy of these standards can be found within appendix 2 of this response. Unfortunately in this instance, whilst the discharge letter addressed all the key areas outlined within the standard/template, the information contained within the letter was inaccurate in this single point and failed to include details of this overdose. As a Trust which constantly looks to improve its services and learn lessons from incidents, the Trust will conduct a review of its standards around discharge communications and reiterate the importance to medical staff that incidents and risk factors are included within discharge letters where this is necessary. It should also be noted that consultant teams also undertake audits in relation to the quality of discharge letters and communication with GPs to ensure / monitor the quality of discharge communication and ensure that the standard of these letters remains high. A required frequency / standard of audit and checking will be agreed as part of this review and will be communicated to medical teams. A summary of these proposed actions is outlined within the enclosed appendix 1. I trust that the proposed course of action addresses the areas of concern outlined within your regulation 28 report to the Trust however should you have any further concerns please do not hesitate to contact us for more information. Yours sincerely Mark Axcell Chief Executive Officer
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