Andrew Collins

REGULATION 28: REPORT TO PREVENT FUTURE DEATHS

REGULATION 28 REPORT TO PREVENT FUTURE DEATHS |

THIS REPORT IS BEING SENT TO: The Chief Executive of
Tameside and Glossop Clinical Commissioning Group (CCG).

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 9" April 2018 | commenced an investigation into the death
of Karen Moran. The investigation concluded on 4" October
2018 and the conclusion was one of Accidental Death.

The medical cause of death was 1a) Combined effects of
dihydrocodeine, gabapentin, diphenhydramine and
chlordiazepoxide.

Karen Moran had memory difficulties and long-standing
pain for which she was prescribed medication. On 7th
April 2018, she was found at her home address and
taken to Tameside General Hospital where resuscitation
attempts were unsuccessful. Toxicology showed raised
levels of dihydrocodeine and gabapentin (prescribed

medications). There were no suspicious circumstances
or third party involvement.

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. —
The inquest heard that:

She had a long term addiction to prescribed medication that
had been recognised. Medication continued to be prescribed
on repeat prescriptions with no referral to address the
addiction. The prescribing pattern meant she had access to
significant amounts of prescribed medication.

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 io this report within 56 days of
the date of this report, namely by 17" January 2019. 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 namely, he
deceased’s mother, 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 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

22.11.2018

Yi
f, Q. GIG Nee auamuiwians Cymru

X or NHS Le nlgean TL Ta Services

rust

Pencadlys Rhanbarthol Ambiwlans a Chanolfan Cyfathrebu Clinigol
Regional Ambulance Headquarters and Clinical Contact Centre
Ty Vantage Point / Vantage Point House, Ty Coch Way, Cwmbran NP44 7HF
Tel/Ffén 01633 626262 Fax/Ffacs 01633 626299
www.ambulance.wales.nhs.uk

CHAIR AND CHIEF EXECUTIVE’S OFFICE
Our Ref: JK107/5449/dr
26 November 2018

Private and Confidential
Mr A Barkley

Coroner's Office

1° Floor

Rock Grounds

Aberdare

CF44 7AE

Dear Mr Barkley
Re: Regulation 28 relating to Inquest of Andrew Collins

| am writing in response to the Regulation 28 Report, to Prevent Future Deaths Issued to
the Welsh Ambulance Services NHS Trust (the Trust} on 2 October 2018. This was issued
following the conclusion of the inquest for Mr Andrew Collins.

The Trust acknowledges your concems regarding our lack of resourcing, which meant that
there was a significant delay in attending to a critically unwell patient.

The supporting information accompanying this letter, highlights the strategic and
operational quality improvements in patient safety that have been completed or are
underway. These are aimed at alleviating harm by improving our available resources to
respond to patients within our communities. Continuous improvements are ongoing with
our Health Board colleagues and we are working collaboratively to progress safety,
effectiveness and a positive experience for patients and their carers.

The key initiatives that the Trust are continuing to working on, to deliver and enable an
improved resourcing picture include, the following;

e That planned resources are sufficient to meet overall demand
e That we align production against demand by local and time of day
e That we reduce sickness absence
e That we reduce handover to clear duration
Casenen Wiatieoweehel Ssecwes oven tons

Mae'r Ymddinedolosth yn croesawy gohebieeth yn y Gymraeg neu Saesneg
‘The Trust weomes correspondence in Welsh or Engistr

e That we introduce safe alternatives to responding to scene where this is
appropriate

e That we reduce conveyance where safe and appropriate and provide care in the
patients home utilising advanced practitioners

The accompanying action plan will provide you with the detail of this work, in addition to
other quality improvement initiatives designed to safely release resources to respond to
patients in greatest need. This includes the introduction of a Falls Framework and
increasing scope of practice for our Community First Responders.

In addition to the actions contained within the attached plan, the Trust has undertaken and
completed a robust review of the “Explorer Project”. The aim of this was the introduction
of “ring fencing” to stabilise resource capacity in the Cwm Taf area and to prevent the
migration of emergency resources into busier adjacent Health Board areas.

The Explorer Project was a joint programme of work between the Trust and the Cwm Taf
University Health Board (CTUHB) designed to improve ambulance response times in the
Cwm Taf area of Wales.

| would like to reassure you that the Welsh Ambulance Services NHS Trust and Cwm Taf
University Health Board, continue to work in collaboration to drive the improvements
forward. We continue to strengthen the out of hospital alternative pathways to improve
efficiency and effectiveness of care for our patients and make best use of our resources.

We hope that we have been able to assure you that we remain focused to improve our
services together and that actions taken to date have had an impact in relation to all of the
areas identified within this Regulation 28 Report.

| would like to extend the offer to meet with you to discuss our response in more detail and
to provide you with assurance of our commitment to the continuous improvement our
service provision.

Yours sincerely

Pada

Jason Killens
Chief Executive
Welsh Ambulance Services NHS Trust