Prevention of Future Deaths reports · 2017
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 report | 17 Nov 2017 |
|---|---|
| Reference | 2017-0403 |
| Deceased | Paul Mullen |
| Coroner | Alan Walsh |
| Coroner area | Manchester (West) |
| Category | Mental Health related deaths · Other related deaths |
| 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 (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
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.
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