Prevention of Future Deaths reports · 2018
Regulation 28 report to prevent future deaths, reference 2018-0042, written 13 Feb 2018. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 13 Feb 2018 |
|---|---|
| Reference | 2018-0042 |
| Deceased | Angela Byrne |
| Coroner | Fiona Wilcox |
| Coroner area | London Inner (West) |
| Category | Alcohol, drug and medication related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | none published |
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
REGULATION 28 REPORT TO PREVENT FUTURE DEATHS
THIS REPORT IS BEING SENT TO:
Chief Executive,
Wandsworth Consortium Drug and Alcohol Services,
St John’s Therapy Centre,
162, St John’s Hill,
Battersea,
London,
SWITISW
1 | CORONER i
| am Dr Fiona J Wilcox, HM Senior Coroner, for the Coroner Area of inner West London
2 | 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.
3 | INVESTIGATION and INQUEST
On 9" January 2018, evidence was heard touching the death of Ms Angela Caroline
Byrne. Ms Byrne had died at home on 29" July 2017. She was 54 years old at the time
of her death.
The findings of the court were as follows:
Medical Cause of Death
1 (a) Methadone toxicity
II Hepatitic Cirrhosis
How, when and where the deceased came by her death:
Angie had a long history of relapsing and remitting drug misuse. On 29/07/2017 she
took an accidental overdose of prescribed and illicit drugs which led to and caused her
death.
Conclusion of the Coroner as to the death
Misadventure
CIRCUMSTANCES OF THE DEATH
Ms Byrne had a very long history of drug dependence and drug misuse for which she
was under the care of Wandsworth Consortium Drug and Alcohol Services. Her
engagement in support services was erratic. She was on a long list of prescribed
medication, namely pregabalin, metformin, mirtazapine and zopiclone and had recently
been started on methadone, despite a history of impulsive binge drug taking. This was
potentially more dangerous for her in overdose that the buprenorphine that she had
been previously prescribed. She would intermittently also take drugs that she obtained
illicitly for example benzodiazepines. She was at risk of sudden death due to respiratory
depression from a combination of methadone, benzodiazepines and pregabalin. On 14"
July 2017 she had been admitted to hospital unconscious after bingeing on prescribed
and illicit drugs and discharged on the methadone which ultimately caused her death.
The evidence was that W-CDAS who knew her better would not have prescribed this,
but rather left her on drugs less risky in overdose, namely buprenorphine. It would
appear that they were not consulted and this was exacerbated by two separate systems
of clinical notes for in-patients and community patients. W-CDAS suggested that she
switch back to buprenorphine rather than methadone to try and mitigate that risk but she
declined.
She denied any current suicidal intent.
On the last day of her life she appeared in normal mood and had plans to go out her
partner that evening on his return from home. Sadly he returned home to find her
deceased and she was recognised at life extinct at 00:15 hours on the 29" July 2017.
On Friday 28". July she had taken a supervised dose of methadone in the chemist and
then brought home with her the doses for Saturday and Sunday.
It was found that she had taken some of this methadone on top of her daily prescription.
Whilst she was under the care of W-CDAS there was evidence that there was only
occasional urine drug screening. This should have occurred more often. There was also
evidence taken that that she should have been under the core team to allow closer
prescribing and dispensing supervision, that her suicidal ideation had not been
documented and that there was no crisis plan in place.
Whilst care in keeping with her risks and complexity may have prevented her death, it
could not be said on the balance of probabilities that it would have done so.
There was concern expressed in the evidence that the practitioners involved in her care
were not always applying the training that they had received appropriately, for example
not documenting her suicidal and self-harm risks, and not completing a crisis plan.
The main problem was said to be the fact that she was not under the core team, but
instead had care and prescribing shared with the GP.
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. The staff at W-CDAS are not applying the training that they receive in practice.
2. That as a result of this, vulnerable patients such as Ms Byrne do not have their
tisks appropriately assessed and planned for.
3. That communications between the inpatient and community services need to be
improved.
4. That consideration be given to one consistent set of clinical records for both in-
patients and for use in the community. :
5. That patients with complex needs such as Ms Byrne are treated by the core W-
CDAS team rather that via shared care with the GP.
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. It is for each addressee
to respond to matters relevant to them.
YOUR RESPONSE
You are under a duty to respond to this report within 56 days of the date of this report. |,
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 : ,
1.
Consultant Psychiatrist,
St John’s Therapy Centre,
162, St John’s Hill,
Battersea.
SW11 1SW.
| 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.
13" February 2018
{a
Dr Fiona J Wilcox
HM Senior Coroner
Inner West London
Westminster Coroner’s Court
65, Horseferry Road
London
SW1P 2ED
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