Prevention of Future Deaths reports · 2018
Regulation 28 report to prevent future deaths, reference 2018-0009, written 12 Jan 2018. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 12 Jan 2018 |
|---|---|
| Reference | 2018-0009 |
| Deceased | Pauline Pryor |
| Coroner | Emma Carlyon |
| Coroner area | Cornwall and the Isles of Scilly |
| Category | Hospital Death (Clinical Procedures and medical management) 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.
REGULATION 28: REPORT TO PREVENT FUTURE DEATHS Pauline May Pryor REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: 1. The Chief Executive of NHS England CORONER | am Dr E Emma Carlyon, the Senior Coroner for the coroner area of Cornwall and the Isles of Scilly 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. INVESTIGATION and INQUEST An Investigation into the death of Pauline May Pryor was opened on 17" July 2015 and an inquest opened on 20" January 2016. An Inquest hearing was held on 14" November 2017 at Truro Municipal Buildings, Truro where the cause of death was found to be 1a Bronchopneumonia 1b Chronic Obstructive Pulmonary Disease II Renal failure, Lithium Toxicity and the death was considered to be the result of natural causes. CIRCUMSTANCES OF THE DEATH Pauline Pryor suffered from bi-polar affective disorder and was being treated with Lithium. She was a resident of Trevaylor Nursing Home, Newmill Road, Gulval. On gt" July 2015 she was found in her room with reduced conscious with the occasional arm jerking. She was admitted to the Royal Cornwall Hospital, Treliske, Truro and diagnosed with acute kidney injury, severe metabolic acidosis, septic shock of uncertain cause and lithium toxicity. She received renal replacement therapy which improved her kidney function and lithium toxicity. She deteriorated and died on 13" July 2015 from bronchopneumonia as result of her severe chronic obstructive pulmonary disease. She was on Lithium which required her to have quarterly blood tests which due to communication issues between the GP surgery and Nursing Home did not occur. A reply to a letter from the mental health service to the GP was not actioned due the GP not receiving due to the e-mail not being received by the GP for unknown reasons or being chased up. 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. — e Mrs Pryor suffered from bipolar affective disorder and was on Lithium treatment which had been successful for many years in controlling her mood. Patients on Lithium are required to have quarterly blood tests to check kidney function and lithium levels. This was not carried out for a number of reasons to do with unclear communication between the Nursing Home and GP surgery. The practice did have in place a computer system to highlight test/reviews for certain groups of patients based on “Quality Outcome Framework Targets” (QOF) guidelines and were unaware these did not necessarily mirror the NICE Guidelines or Local Prescribing /Care Guidelines such as in the case of Lithium Toxicity e ABlood test on 29" April 2015 showed Mrs Pryor’s kidney function dropped (EGFR 25) and despite a lithium test being requested by Nursing Home and GP it did not occurred. As a result of the kidney function test result the GP wrote to Mrs Pryor’s Consultant Psychiatrist for advice on medication. The Psychiatrist replied by e-mail on the 15.6.15 and advised the GP to reduce and stop the Lithium medication. The E-mail was sent to the GP Practice e-mail but was not seen by the GP for reasons unknown nor was the reply chased up ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and | believe you AND/OR your organisation have the power to take such action. 1. To highlight the importance/requirement of good clear communication between health agencies when medical and nursing care is shared between the Mental Health Trust, GP and Nursing Homes especially where the patient is suffering from Mental Health issues 2. To ensure that all GP’s are aware the QOF targets do not necessarily mirror NICE Guidelines or Local Prescribing /Care Guidelines e.g. Lithium Treatment; and the requirement for GP’s to have their own systems in place to monitor the timeliness of tests/reviews YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 12" March 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. COPIES and PUBLICATION | have sent a copy of my report to the Chief Coroner and to the following Interested Persons pres memes ori Cornwall Partnership i Chief Operating Officer of Swallowcourt Of Alverton GP Practice. | 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. [DATE] [SIGNED BY CORONER] 12/04/2018 CLigoleir Crone Cryer
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.
23rd January 2018 Addressee Only: Private Dr Emma Carlyon Sent via email cornwallcoroner@cornwall.gov.uk South, South West Medical Directorate Peninsula House Kingsmill Road Tamar View Industrial Estate Saltash, PL12 6LE Email: Liz.thomas2@nhs.net Tel: 0113 824 8794 Dear Dr Carlyon, Reference Regulation 28 Report following the inquest of Pauline Pryor 1. Patients with serious mental health issues are usually cared for by a number of agencies and they may lack capacity or it may be intermittent, it is vital communication is effective. Statutory agencies such as the mental health services and GP surgeries have long standing means of communications when formally referred and treated. However, this case has raised the need to ensure the occasional interval communication is treated as formally. In addition when patients are cared for in a residential or nursing home setting then it is equally important that any verbal message is followed up by written instructions if possible. NHSE will raise this concern in our GP bulletin and also provide information to the LMC for distribution. 2. Lithium monitoring. Thank you for pointing out that the QOF framework which is designed to reward GPs for quality, is not the mirror of lithium monitoring guidelines. We will ensure that this is highlighted to GPs and practices and a reminder that up to date guidance is available from the latest BNF, and also local CCG prescribing guidelines. I have attached for your information the proposed communications. With best wishes, Yours sincerely Dr E Thomas Deputy Medical Director NHS England South, South West
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