Prevention of Future Deaths reports · 2017

Paul Mullen

Regulation 28 report to prevent future deaths, reference 2017-0403, written 17 Nov 2017. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.

Date of report17 Nov 2017
Reference2017-0403
DeceasedPaul Mullen
CoronerAlan Walsh
Coroner areaManchester (West)
CategoryMental Health related deaths · Other related deaths
Sourcejudiciary.uk record · original PDF
Responses published1

The report

Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.

REGULATION 28:  REPORT TO PREVENT FUTURE DEATHS (1) 

NOTE: This form is to be used after an inquest. 

REGULATION 28 REPORT TO PREVENT FUTURE DEATHS 

THIS REPORT IS BEING SENT TO: 

1.  Bev  Humphrey,  Chief  Executive,  Greater  Manchester  Mental  Health  NHS 
Foundation  Trust,  Trust  Headquarters,  Bury  New  Road,  Prestwich, 
Manchester M25 3BL. 

2.  The Chief Pharmacist, Hindley Health Centre Pharmacy, 17 Liverpool Road, 

Hindley, Wigan WN2 3HQ. 

1  CORONER 

I  am  Alan  Peter  Walsh,  HM  Area  Coroner  for  the  Coroner  Area  of  Manchester 
West. 

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  27th  June  2017  I  commenced  an  Investigation  into  the  death  of  Paul 
Geoffrey  Mullen,  37  years,  born  19th  February  1980.  The  Investigation 
concluded at the end of the Inquest on the 6th November 2017. 

The medical cause of death was:- 

Ia  Combined Toxic Effects of Heroin and Methadone. 

The Conclusion of the Inquest was Drug Related Death. 

4  CIRCUMSTANCES OF THE DEATH 

1.  Paul  Geoffrey  Mullen  (hereinafter referred  to  as  “the  deceased”)  died  at 

 Wigan on the 22nd June 2017. 

2.  The deceased had been taking drugs from the age of 18 years and he was 
known  to  be  a  long  term  user  of  heroin,  crack  cocaine,  diazepam  and 
tramadol.  He was well known to treatment services and he had numerous 
treatment episodes in Wigan and Leigh since 2008. 

3.  The  deceased  was  referred  to  the  Wigan  &  Leigh  Recovery  Service  under 
the umbrella of Addaction (hereinafter referred to as “Addaction”) following 
a referral from prison upon his release from prison on the 12th April 2016.   

1

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 All  referrals  into  Addaction  go  via  Greater  Manchester  Mental  Health  NHS 
Foundation Trust (hereinafter referred to as “GMMH”), who also deliver any 
medical  interventions. Addaction  deliver  recovery  focused  work  for  those 
affected  by  substance  misuse  and  their  families  through  specialist 
psychosocial one to one work and specialist tailored group work sessions to 
develop recovery focused plans. 

The deceased was assessed by GMMH, which is the prescribing partnership 
for Addaction, and he was referred to Addaction for case management. 

Following  the  initial  assessment,  a  Recovery  Plan  was  completed  and 
objectives were agreed around substance misuse to stop illicit drug use and 
adhere  to  methadone  treatment.  The  deceased  was  prescribed  60ml 
methadone  daily,  which  was  to  be  collected  from  a  pharmacy  on  a  daily 
basis. 

The designated pharmacy was Hindley Health Care Pharmacy, 17 Liverpool 
Road, Hindley, Wigan (hereinafter referred to as “the Pharmacy”)  

4.  Over  the  next  12  months  the  dose  of  methadone  was  varied  and  the 

deceased did not attend a number of appointments with Addaction. 

Th 

The last face to face appointment with Addaction was on the 26th April 2017 
when  the  deceased  attended  Addaction  without  an  appointment.  At  that 
time  he  was  receiving  50ml  methadone  by  a  daily  prescription  which  was 
collected from the Pharmacy each day, except Sunday. He was encouraged 
to  seek  further  medical  intervention  in  relation  to  his  physical  and  mental 
health.  He failed to attend a number of appointments with his Key Worker 
at Addaction in May and June 2017, including a medical review.   

5.  In spite of his failure to attend his appointments the deceased collected his 
methadone prescription on a daily basis from the Pharmacy and he was very 
diligent collecting his methadone prescription each and every day. 

On  the  15th  June  2017  Addaction  sent  a  letter  to  the  deceased  explaining 
that he had missed four appointments with Addaction and that his failure to 
attend the next planned appointment on the 21st June 2017 would result in 
his methadone prescription being placed on hold. GMMH  were informed of 
the letter by Email.   

On the 21st June 2017 the deceased did not attend an appointment with his 
Key  Worker  at  Addaction  and  the  Key  Worker  telephoned  the  Pharmacy 
asking them to place the deceased’s prescription of methadone on hold to 
encourage his attendance at Addaction. 

     On the 22nd June 2017 the Key Worker again telephoned the Pharmacy to 
     check whether the deceased had attended to collect his methadone and 
     whether he had been informed that the prescription had been placed on 
     hold. The Key Worker was informed that the deceased had not attended 
     and, in fact, had not collected the methadone on Monday the 18th June 
     2017, Tuesday the 19th June 2017 and Wednesday the 20thJune 2017.   

2

 
 
 
 
 
 
 
 
 
 
 
 
 The Key Worker emailed GMMH on the 22nd June 2017 to confirm the above 
circumstances. 

6.  At or about 14:55 hours on the 22nd June 2017 the deceased was diagnosed 

as having died at his home address at 

. 

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.  During the Inquest evidence was heard that:- 

i.  The  deceased  was  receiving  a  daily  prescription  of  methadone  to  be 
collected  and  administered  on  a  daily  basis  from  the  Pharmacy.  The 
prescriptions were not collected from the Pharmacy on Monday the 18th 
June  2017,  Tuesday  the  19th  June  2017  and  Wednesday  the  20th  June 
2017.   

ii.  There is a system, referred to at the Inquest as a “red flag system”, for a 
pharmacy  to  report  the  non-collection  of  a  prescription  of  methadone 
when  a  patient  has  not  collected  the  medication  on  three  consecutive 
occasions. The evidence at the Inquest indicated that the purpose of the 
report by a pharmacy of non-collection is to enable the Key Worker to be 
made  aware  of  the  non-collection  of  the  medication  so  that  the  Key 
Worker could take appropriate action to contact the patient and to check 
whether any concerns need to be addressed. 

iii. The Key Worker attached to the deceased was 

, who 
is a Key Worker employed by Addaction, and she gave evidence that the 
procedure  relating  to  the  deceased,  and  other  patients,  to  report  non-
collection  of  medication  is  for  the  report  to  be  sent  by  a  pharmacy  to 
GMMH and not directly to the Key Worker. In the case of the deceased, 
, the deceased’s Key Worker, did not receive a report 
that the deceased had not collected his  methadone on the above dates 
and  she  only  became  aware  of  his  non-collection  of  methadone  by  her 
own  enquiry  when  she  telephoned  the  Pharmacy  to  request  that  the 
prescription of methadone be placed on hold.   

iv. 

  also  gave  evidence  that  some  patients,  particularly 
those  patients  who  are  known  to  be  diligent  and  to  collect  their 
medication  on  time  each  and  every  day,  may  require  a  report  of  non-
collection  of  medication  earlier  than  three  days  because,  in  relation  to 
those patients,  a single failure to collect medication may  raise concerns 
and require enquiries by the Key Worker as to any concerns, in view of 
the  fact  that  those  patients  always  collect  their  medication  each  and 
every day.  

3

 
   
 
 
 
 
 
 
 
 
 
 
 
 v.  GMMH is a Mental Health NHS Foundation Trust and is separate in terms 
of  governance,  even  though  working  in  partnership  to  an  extent,  from 
Addaction,  which  is  described  as  a  Drug,  Alcohol  and  Mental  Health 
Treatment Charity. Accordingly, any report relating to the non-collection 
of medication addressed to GMMH requires a further onward report from 
GMMH  to  Addaction.  The  governance  of  GMMH  has  no  control  over 
Practitioners  employed  by  Addaction  and  GMMH  and  Addaction  do  not 
share computer reporting systems. 

2.  I request a review of the system referred to at the Inquest as the “red flag 
system” in relation to the reporting of patients who fail to collect prescribed 
medications,  particularly  where  the  patient  is  due  to  collect  prescribed 
medications on a daily basis. 

The review should consider:- 

i.  The  reporting  of  a  failure  to  collect  prescribed  medication  direct  to  a 
designated  and  named  Key  Worker,  who  may  not  be  within  the 
employment  of  GMMH,  to  avoid  the  report  being  processed  by  an 
intermediary, who does not employ or control the Key Worker.   

The  review  should  consider  the  most  expeditious  route  to  report  the 
failure  to  collect  prescribed  medications  to  a  Key  Worker,  who  has  the 
responsibility  in relation to the patient  and who  will have direct contact 
with the patient. The Key Worker will be the most expedient method of 
contact with the patient. 

ii.  The timescale in relation to a report being submitted to the Key Worker, 
taking account of the fact that the present three day timescale may not 
be appropriate for patients who are known to be very compliant and who  
collect prescriptions on a regular daily basis. In those circumstances the 
concern and the need to check the concern may arise after either one or 
two failures to collect the prescribed medication. 

iii. The  training  of  pharmacy,  mental  health  practitioners  and  any  other 
healthcare professionals  in relation to the reporting of failures to collect 
prescribed medication taking account of the circumstances relating to the 
case  of  the  deceased,  where  the  failure  to  collect  the  prescribed 
medication  was  not  reported,  as  soon  as  practicable,  after  the  third 
consecutive failure to collect the medication. 

6  ACTION SHOULD BE TAKEN 

In  my  opinion  urgent  action  should  be  taken  to  prevent  future  deaths  and  I 
believe that you have the power to take such action. 

7  YOUR RESPONSE 

You are under a duty to respond to this report within 56 days of the date of this 
report, namely by 12th January 2018.  I, the Coroner, may extend the period. 

4

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 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:- 

1. 

2. 

 Mr Mullen’s mother, 

Dorning Street, Wigan WN1 1HR. 

, Service Manager, Addaction, Coops Building, 11 

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  Dated 

Signed 

17th November 2017 

Alan P Walsh 
HM Area Coroner 

5

Responses

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.

Response from S (PDF)
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“squeuquiodde aaynoesuod no Jaye Ajjensn “SBA[BSWSU} UOROEPpY YIM sJUsWJUIOdde puaye
0} payiey Ajpeyeedes aney sjusyed uaym Adewueyd AYUNWWOd dy} 72 ,PIOY UO, Wey} ynd 0} si
uM 24} uly suoRdiosaid 07 preBas YM suaiom UoRoeppYy Jo yndul Ajuo ay “Buiquoseud
ayes BuloBuo s| ans! jeon1i9 ayy asnesagq UO}}99]|09-UOU Jo suJayed Jo ssauereme alinbas OUM
Jaxomhay uoloeppy ey} jou pue HW Ajueuuiid st H SuOJesay] “JaxJOAA UOSIEr] AoeWWeUE
HWS ou) pue sueiiuo Buiquoseid HWS 34) ove Aoeuueyd 84} WOly sasuedsip yoaljoo
0} SeJnyfe) JO ssoueJeme auinbel OUM sjenpiAIpul Arewuud au) yeu) YEUBIY 0} aI] PINOM aAA

“ADYION
Asay au} [0.11U09 10 Aojdwie jou Sop OUM ‘(ueipsuueyul ue Aq pessedoid Bulag yodal
2U} PIOAE 0} ‘HININS JO JuawWAO|dUe 9Y}) UUW 9q Jou Aew OYM “Iays0AA Aoy poweu
pue payeuBbisep e& 0} Joal1p UOnesIpau pequoseid 309/09 07 aunjey e& yo Buysodas ay

vio gated saary Buiaciduyy

‘Bupyiom diysuauped dojanep Jeyyny 0} Jepso Ul ajoJ sIy pue jlaswIy sonpodUt
A\jeuosiad pue ,ajni Aep 9eiy}, ay} Jo ssouaseMme osjes AjeliIs 0} BLO Alenuer Jo pua au)
Aq saioeuueyd Ajtunuwos ye yoeju0o Ajaaoeodd JIM JE LOA, uosier Aoeuueyd su} ‘uoHippe
ul *,aind Aep saiuy, au} jo ssauaieme asies pue peste: avey noA suseou0d au} 0} UONUATE
A194} MEIP 0} SaWIWWOD jedjnssewJeyg (e007 pue dnosg Buluolssiwoy jeoluiig au}
YUM suoIssnosip eaey 0} pebuewe sey Jabeueyy jeuoiessdO HWS eu} siy} 0} asuodse uy]
“s}sioeueyd AyuNnutluod jo Apog ay} uIyWIM ain Aep ea.u}j, ayy Jo souevodu! ay} Jo ssaudJeEMe
40 yor] e aq Aew dJay} Jey) sieadde 1 pasies aAey NOA susJe0U02 OY} JO Maina e BUIMO||O4

“AJGAODSI O} BANSISSE BIE YOIUM SpIAosd ABU}
S}USWWA/9 UOTUSAIa]U! JeEIOOSOYoAsSd ay} YIM JUsLUaGebue BujoWoJd Jo asodind ay} 40) siu} op
Asy, ‘sjueujulodde aninoesuos sno} seye Ajensn ‘seajasweuy UoNIeppYy UIIM s]UaUUIOdde
pusye 0} pares Ajpayeaday aney sjuayed uaym Aoewueyd AjunWWoo 84} ye ,pjoy UO, Wau}
ind 0} SI GYTM eu} UIYIIM sUOIduoSseld 0} preBau YA suayJom UOHOeppy Jo Indui Ajuo ay

‘ysed ay} ul
SUOP BABY BM YOIYM HOD 24} Jo/pue seYILUWOD jedIjNSDeWUeY, [2907] 94} Aq paysanber s! siuj
aJaUuM s}sjoewseyd 0} soneniul Buiuresy Aue Yoddns 0} sanujuod HIND ‘isn uoHepunoy
SHN syBnovog sai YON Aq ye}s Ueay je}UeWW pue ‘uoOeppy Aq YeIs UONIeppY jo esou}
(999) dnosy Buuoissimwog jeoiujg ou} pue (9qg7) eeywWED jeoNNedeWJeY_ |2907 au}
Aq Ayewud pauiwayap aq jim s}sioewueyd Ayuntuwos jo speau Bulules) ey] ‘UMO Jay) UBUY
Jayjo saiouabe Jeyjo ul yeys Jo Bulures} Uodn }s|sul Jou ‘auinbad ‘auiWa}ep 0} a[ge JOU Ss! HIND

“anuljuod pjnoys jueweeBe siu} yeuy st uo!UIdo
$,wea} Buimeiras ay} pue ‘axoa, uosler] AOeWeYd HININS eu} YyBnolul peynoi ase ‘siayom
uoloeppy JO s}sioeweyd Woy Jayjeym ‘suoeaiuNWWWOS {Je Jey} UOHe}Oadxe pesube au) useq
skemje sey }| “ain Aep aaj}, au} Jo JuIOd auy S| YoU ‘Buiquosaid jo Ajajyes a4] JO SUOSBAL JO4

“UOHESIPSW 9U3 J99]}09 0} a4njle} BAYNDeSUOD ply} 9Y} Joye
‘ajqeonoeid se uoos se ‘payiodal jou sem UOeo|peu paqlosaid au} }9a]]09 0} aunpley
3y} a18yM ‘paseadap ay} Jo eased ay) 0} BuReje: SaouejsuNouID ay} Jo JuNODDe Bulye}
uojeo|paw paqiuosesd 499]/09 0} sainpiey so Bunuodas ay} 0} uoejai ul speuolssajoid
areoyyeeay sayjo Aue pue siauogjoeid yyeay yeyuau ‘Aoewueyd jo Buluiery ayL

“gina Aep saiuj, ayy Burmojjoy Aqjuazsisuos Aq Ajeyes ajowoud ysaq
“Salyed [je ‘asuas yey} ul] “Ajayes Jo SUA} UI ANSs} BONUS Oy} SI YOIYM ‘BOUeJA[O} JO YOR] SIL}
S| }! pue ‘Jso| 8q 0} uiBeq Aew spioido 0} souesa[o} YoIUM Ul poLiad [eo ay} SI eso 10 skep
ddJy} JEU) SesIApe yOOg SHueiO ay} UUM JUSJEYUI SOIApe |BIIUI|O BY, ‘asuadsip suo passiwu
juaned e sul] AlaAa pue YOee HID asiApe 0} Aoeweyd AjuNuUWCd JO} o1Ns1/ea4UN aq pINoM }|

UOIJESIPSU paqiosaid 9} JI9[JOO 0} SauNp1ey OMY JO BUO JOYUO
daye ase Aeul us99U09 843 49949 0} p99U BY} PUL UIBDUO0D ay} S8DUR}SUINIIID BSOY} U|
‘siseq Ajrep sejnBal & UO SUONdIs9Said J99]]09 OYM pure jUeT]dWOD Alaa aq 0} UMOUY ale
OYM sjyualjed 10) ayeludoidde aq jou Aeu ajeosou Aep 9914} Juesesd 8y} }eU} JOE) 94} Jo
qunosse Burye} “ayiofya Ady ou} 0) peywiqns Bulag yoda, e 0} uoNea Ul ajeosowH ay

vio yebed Saar] BulAosduyy

SANOOXA JO1YD
Aesyduiny Agyeacg

Ajeseouls sino,

‘uoRe[ndod Jasn solAjas ay} 104 UOWSUeN YJooWS pue ajes 2
SdNsus 0} sounseew Aiessedeu Aue aoed ul nd |[IM pUue SUU9}SAS S}I JO MAIAAL {IN} B pajejduioo
SEY HID Jeu} Jtenemoy nod aunsse 0} ayy pinom 28M “Jepiaosd ajos |y} awozeq {IM
UOHSEPPY PUB '@SB80 |IIM JOBJJUOS 94} YOIUM JOYE BL/E/LE (HUN Fe 8u} Ul steplAoid jeoiuljo
Su} 8q 0} UEWaL AjUO TIM HIND Jey) aueme SISUOIOD UOJOg JNO eye O} SyI| PINOM SAA

“Ajsno|as sanbul s,ualnyy JW Buunp pesies susaouoo Oy} Ueye} sey YSN
OY} 724} JlasINOA pue Alley s,UBI|INW JW 0} goleINsse sepiaoid asuodsai si} yey} adoy apy

“JED S,JENDIAIPU! UE U! PAA|OAU! U@aq aABY SAdIAJes JSNJ{ Uy Jo Aue ji Ayejnomred
SUOISN|DUOD Jay JO siy Bulyoeas Ul JeU0J0D ay} ysisse Aem Aue UL UBD SIU} jl BOUapIAS apiAold 0}
SJ9UDIOD Ino Aq pales Buleq enjen skemye SUBDIUIID HIND ‘HIND pue uooeppy usamjaq
diysusupeg Aeacosy yBie7 pue ueBiAA 3y) UILIM aoe/d UI Saunpadold ay} JO JuNODDe Jealo e
6ulpiaoid ul paysisse aaey Kew YOIYM ‘Jsenbul s,uayni) JW Je BUuapira aaib o} POPAU! jou sem
‘Jsanbu/ ey} 0} pUaWayE}s e payWans ou ‘40}90q Buiquoseid HWW eu} Jeu) 38469 Jo I 1]

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