Prevention of Future Deaths reports · 2018
Regulation 28 report to prevent future deaths, reference 2018-0135, written 8 May 2018. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 8 May 2018 |
|---|---|
| Reference | 2018-0135 |
| Deceased | Jonathan Earp |
| Coroner | Caroline Saunders |
| Coroner area | Gloucestershire |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| Organisation named | Gloucestershire Hospitals NHS Foundation Trust |
| 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.
H M Assistant Coroner for Gloucestershire Ms Caroline Saunders REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: Gloucestershire Hospitals NHS Foundation Trust CORONER | am Caroline Saunders, H M Assistant Coroner for Gloucestershire. 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 the 21/7/2017 | commenced an investigation into the death of Jonathan EARP. The investigation concluded at the end of the inquest on 25/4/18. The conclusion of the inquest was a Drug Related Death. The medical cause of death was determined to be: 1a The combined toxic effects of Alcohol, Diazepam, Pregabalin, Fentanyl, cocaine, Zopiclone, Mirtazepine and Morphine CIRCUMSTANCES OF THE DEATH Jonathan Earp died at 08:15 on 10/7/17 at Gloucester Royal Hospital from the effects of prescribed and non-prescribed drugs 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. — | heard during the inquest that Mr Earp had been prescribed Fentanyl which was administered by way of transdermal patches. Mr Earp repeatedly requested additional patches however there was no evidence that all of the “unspent” patches had been returned to the nursing staff or appropriately discarded. The clinical staff believed that Mr Earp was accessing illicit drugs when he left the ward, however there was no evidence that staff considered that he may have been taking additional Fentanyl and illicit medication, and the effect this could have. | would ask that consideration is given to providing staff with guidance on how to manage the administration and provision of prescribed drugs when the patient is also accessing non- prescribed potentially illicit drugs Gloucestershire Coroner's Court, Corinium Avenue, Barnwood, Gloucester, GL4 3DJ Tel 01452 305661 | Fax 01452 412618 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 4pm on 10/7/18. |, 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) —_— and brother of the deceased) (2) (3) | 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. Dated 8/5/18 Signature Carole i) Caroline Saunders H M Assistant Coroner for Gloucestershire Gloucestershire Coroner's Court, Corinium Avenue, Barnwood, Gloucester, GL4 3DJ Tel 01452 305661 | Fax 01452 412618
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.
INHS Gloucestershire Hospitals NHS Foundation Trust Alexandra House Cheltenham General Hospital Cheltenham Gloucestershire GL53 7AN Tel: 0300 422 4721 e-mail: deborah.lee2@nhs.net g July 2018 Ms Caroline Saunders HM Assistant Coroner for Gloucestershire Gloucestershire Coroner's Court Corinium Avenue, Barnwood Gloucester, GL4 3DJ Dear Ms Saunders The Late Mr Jonathan Earp | am writing in response to the letter dated 8 May 2018 from your Officer I enclosing the Regulation 28 Report to prevent future deaths. The Trust has noted your outstanding concerns as described in paragraph 5 of your Report. Following the inquest, the Trust has further reviewed the circumstances of the administration of fentanyl to Mr Earp. Under the direction of Mr Steve Hams, Director of Quality and Chief Nurse, this case has been discussed with the ward staff who looked after Mr Earp, and has been presented to the Senior Nurse and Midwifery Committee. The enclosed Action Plan confirms the work which the Trust has undertaken, and continues to work on, as a result of Mr Earp’s death. The Trust Quality Delivery Group will maintain oversight of these actions and ensure they are being delivered. | hope this is helpful. Please do not hesitate to contact me if you require further information Yours sincerely Wooom. Lv Deborah Lee Chief Executive Chair: Peter Lachecki Chief Executive: Deborah Lee BEST CARE FOR EVERYONE www gloshospitals,nhs,uk 740 4 a6@q JSIOBUUEYd ayaiduiod 8L07 YEW pee) yeyo Srup esipsepuejs pue MalAoy (WWdOd) pled uonoe SWIGV “MAIASI [EOIPSW INOYWM PaJE]SIUIWPE-aJ Bq 0} JON ‘YOIed peaowsa yueynsuog JO \so| 8q sayojed jeuuepsuey 8102 aleD Buiquosaid pinoys ‘uojesipew Buluue|d Jequiajdas painpeyosun, 81 JAPISUCD PUB UONESIPSLU MBIAGI 0} JeNSIBAY 0} aJeE;eEOSe OL JO MAIABJ JO}OO JOIUaS 8L0c peo] aed el) ASH Je esouy BulAyquep! Buluueld Jequuajdas uoneyW ‘eyeuudoidde ji ased yel| 0} pappe pue pessnosip aq o} syaly spaje Ajayes Jo ssao0y JOsIApy Aynoeg sJnolaeyagq Aysi JO YSU JasiApy Aynoas YM sunoy Jo Jno asn au} auo|dxy ‘jJUaW}ea4 Jo suOneedxe ye SJOSN BdIAIBS B|qesaU|NA Buluue|d LOZ Jequiaydag uojeyy Bunjels ‘s}oeUOD JUSLUJe9d] PUE S}ORIUOD jeEuNoIABYye JO MSIAeY Jo uoeoyUap: AeQ “yeys PJEM 0} YOeEQHee) pue souel|dWoO jo yipne jeaiuljo jNoAUeD -Z JeAowss pue “yoo Brup pajjosjuoo ul sayoyed jeuUepsuUes} de yoyed jewsapsuel} eonoesd JuBUND gLoz Aine JaBeueyy pen, jo eBejsem pue jeaowes ubis JayuN0d pue juawnooq ‘| JO Buvoyuow aAosdwy “sinoiaeyoaq AySi aAey 0} jeUS}Od eojoesd Juang gLoz Ainr JeBeuey,y pen Sy} YM sjuened aiqeyeulna jouq Ajayes yoes ye Aynuepl oL ylys Jed youq Ajayes sasunu payilenb om, Aq abejsem Bnip paljoijuoo |je JUaWINDOP 0} OS|y “yOOg pl0zel Ajiep eojoeld juaUND Loz Aine JeBeueyy plenn Bnup payjosjuoo ul }uswNoOp pue Ajrep shrup payjoyuoa yoo sBrup [oujuoo ay} YOeYO OL snjejs UO!}a|dWOd JO} a3eq ysNjL UONeEPUNOY SHN sjeiIdsoy aslysiaysaznojyH SHIN aiqisuodsa suosied pouuryg uonoy pauinbas uonoy Uejg UOhoy — diey ueujeuor AN ZJ0 z aby 8102 IAT O4 Sd1Ape Bulquoseid 0} souasajel @pnjoul 0} uoWesiueBJo au} “sBuyeow Aay je pue sues} YIM aeYs 0} speoy | ssou9e JuJea| SUOssa] ||e aleYs ayejdwoy Loz Ainr Ayayes jo 10}OaI1q juswyedap pue susBeuew piem j[e 0} Juas aq 0} Buyaiiq Ajayes 0} padojanep Buyaig Ajayes | F mre 4 «SAINITSGIND “e01es AQUepuadep Bniq ay} Jo suapiAd |} Jo\pue Wee} juowebeuew uled eyndy ey} Woy Buiquoseid uo aolape JayUny SASS ens Joy Aemyyed uopejeosa ue sapiaojd pue souepuedap ajeido QYUVM SHL juewabeuey Piqiow-09 aaey oym sjuaned Bulbeuew uo sisioeuueyd pue NO SYASN GlOoldo., vo ajaiduiog 8Loz Ainr Uled B}NOV JO} JUBYINSUOD | SesJnU ‘suO}OOp asiApe 0} dn UMeJp Ueeg eAeY saUl|epinB esau, HeYOMoY pue Adod malAay ysnay UONepuNoY SHN sjezidsoy aslysiaysa2no|y5 SHIN
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