Prevention of Future Deaths reports · 2018
Regulation 28 report to prevent future deaths, reference 2018-0077, written 14 Mar 2018. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 14 Mar 2018 |
|---|---|
| Reference | 2018-0077 |
| Deceased | Peter Stojilkovic |
| Coroner | Alison Mutch |
| Coroner area | Manchester South |
| 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 REGULATION 28 REPORT TO PREVENT FUTURE DEATHS | THIS REPORT IS BEING SENT TO: Heaton Moor Medical Practice, Chief Executive of Pennine Care, Chief Executive of Stockport Clinical Commissioning Group, Department of Health, Mayor of Greater Manchester. CORONER | am Alison Mutch, Senior Coroner, for the coroner area of South Manchester 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 On 25" July 2017 | commenced an investigation into the death of Peter STOJILUKOVIC. The investigation concluded on the 8th February 2018 and the conclusion was one of suicide. The medical cause of death was hanging. CIRCUMSTANCES OF THE DEATH Peter Stojiljkovic was admitted to Norbury Ward and prescribed melatonin to try and address his sleeping problems. It was known that prescribing within the community was likely to encounter difficulties. He was discharged from hospital on 9th June 2017. The plan was for care by the Home Treatment Team until care was taken over by the Community Mental Health Team. This did not happen. On 12th June the GP refused to prescribe melatonin. On 20th June 2017 the psychiatrist indicated a 28-day prescription for melatonin would be given and other melatonin needed to be sourced independently. The GP practice had prescribed melatonin after reconsidering the position. This was not communicated to the deceased or the psychiatrist. On 22nd July 2017 Peter — was found a by a ligature at his home address, 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 deceased had been prescribed melatonin whilst an in-patient. The inquest heard that post his discharge communication between the hospital; GP and Mr Stojilikovic was such that he was unaware that his GP was prepared to prescribe melatonin in the community; 2. Whilst an in-patient the deceased was prescribed a drug melatonin that was on the Stockport CCG blacklist although not on all GM CCG blacklists. It was unclear why Stockport CCG took a different approach too other CCGs 3. The inquest heard that GPs are faced with a mixture of lists regarding prescribing. Nationa! and local. This results in GPs having to negotiate through a complex system when prescribing where there are grey areas that create uncertainty. 4. The deceased was told he would have to source melatonin for himself over the internet if his GP would not prescribe it. This created a risk that he would have to access the drug from unlicensed sources. 5. It was known whilst he was an in-patient that difficulties with prescribing melatonin in the community would arise. There was no evidence of any attempt to communicate with the GP prior to discharge to ensure a smooth discharge into the community. ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and | believe you have the power to take such action. YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 9" May 2018. |, 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 ore brother of the deceased, who may find it useful or of interest. | 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 N 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. Alison Mutch OBE HM Senior Coroner 14/03/2018
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.
RECEIVED 23 APR 2018 YM Ref: 7842/CH HM Coroner South Coroner's Court 1 Mount Tabor Street Stockport SK1 3AG Dear Ms Mutch, Re Peter Stojiljkovic Stockport wn FO YEA Clinical Commissioning Group aca ee 7" Floor, Regent House Heaton Lane Stockport, SK4 1BS Tel: 0161 426 9900 Fax: 0161 426 5999 www.stockportecg.nhs.uk 19" April 2018 Thank you for your letter of 12" March 2018. | would firstly like to pass on my condolences to the family. We very much regret any suicide and welcome a review of such situations. You have set out a range of recommendations, and | have commented specifically on those that relate directly to the CCG. 1. We accept that from the information in the letter that there has been a breakdown in communication with the patient. You have written to the practice and we assume they will respond to that issue. However, our Medical Director will review the case with the practice to identify any further learning. . Melatonin is on both the CCG and the GM restricted lists currently, and CCGs across Greater Manchester aim to have consistent lists as far as possible. Although worded differently the interpretation would be the same in this case. We have not tracked the position of the GM list at the time of the incident, and accept that they may not have been consistent at that time. | acknowledge your point about the difficulties that practices face in navigating through the various different lists, for this reason, as long as a practice works with one of the lists, we would support them in their decision. . The practice followed what we would expect to be the usual process: e They identified that it was not a drug the practice would usually be expected to prescribe e They were prepared to prescribe the first prescription e They applied to the CCG for a review of the case via the CCG’s process. The case is on file at the CCG. A decision would then have been made as fo the clinical reason for the prescription, and if it was appropriate for a GP or secondary care consultant to take the responsibility for Mrs. Jane Crombleholme — Chair Dr. Ranjit Gill - Chief Clinical Officer Mrs. Gaynor Mullins — Chief Operating Officer its prescription. The panel however never reviewed this case as the request was withdrawn. From the dates it would appear that this was following his suicide. 4. We would not expect anybody to be told that they should access medication via the internet and we will discuss this with Pennine Care, and identify any further action that needs to be taken in respect of this finding. However, as you have written to Pennine Care | assume that they will respond to you directly on this issue. In addition, we will raise the issue of how the provision of medication at discharge was handled by Pennine Care, and again identify any improvements that they need to make. | hope that this confirms the CCGs actions in relation to this tragic case. However, if you have any queries, please contact me. Yours sincerely Ges So Dr R Gill Chief Clinical Officer Mrs. Jane Crombleholme — Chair Dr. Ranjit Gill — Chief Clinical Officer Mrs. Gaynor Mullins —- Chief Operating Officer
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