Prevention of Future Deaths reports · 2018
Regulation 28 report to prevent future deaths, reference 2018-0347, written 12 Nov 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 Nov 2018 |
|---|---|
| Reference | 2018-0347 |
| Deceased | Joseph Page |
| Coroner | Graeme Hughes |
| Coroner area | South Wales Central |
| Category | Hospital Death (Clinical Procedures and medical management) 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.
ANNEX A
REGULATION 28: REPORT TO PREVENT FUTURE DEATHS (1}
NOTE: This form is to be used after an inquest.
REGULATION 28 REPORT TO PREVENT FUTURE DEATHS
THIS REPORT IS BEING SENT TO:
The Chief Executive Cardiff & Vale University Health Board
CORONER
| am Graeme Hughes, Area Coroner, for the coroner area of South Wales Central
CORONER'S LEGAL POWERS
i
| 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
{ commenced an investigation on the 28'" March 2018 into the death of Joseph Page.
The Investigation concluded at the end of the inquest on 5" November 2018. The
conclusion was “Suicide” and the medical cause of death was 1a. Multi-Organ Failure
1b. Hypotension 1c. Mixed Drug Toxicity
4 | CIRCUMSTANCES OF THE DEATH
These were recorded as :-
Joseph Page had a number of significant co-morbidities, most notably chronic kidney
disease and ischaemic cardiomyopathy. He was experiencing declining health, which
led to him being admitted to University Hospital Wales on 15.3.18. He was responding
well to treatment, when, and on 22.3.18, he received some upsetting news in relation to
the health of one of his daughters. At, or around 1.45am on 23.3.18 he has deliberately
taken a mixed overdose of his prescription medication. That medication was accessible
to him, & not locked away in his bedside medicine cupboard contravening the hospital's
Medicines Code & patient property policies. Despite treatment thereafter he declined
significantly from around 8am, and likely suffered multi-organ failure, consequent upon
hypotension and overdose. He died at around 9.30am that day.
The Inquest focused upon:-
a. The practices & procedures in place at University Hospital Wales Cardiff ~ both
in the Emergency Department and Ward B5 for receiving, utilising & storing
Patients Own Drugs (PODS) whilst in hospital
b. The treatment received by Mr Page post overdose
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) In the Emergency Department, and whilst patients were awaiting admission to a
Ward, their PODS remained with them unsecured in a bay (or similar). Exposing
the medication to potential further use/mis-use by the patient, another patient or
relative, or theft and mis-use
On ward BS, the policies in place at the time in relation to PODS were not
followed, allowing Mr Page's medication to remain unsecured on the Ward,
exposing the medication as in (1) above.
| received evidence that the Patient Property Policy and Medicines Code were in
the process of being updated to address (1) & (2), but this exercise not expected
to be completed until March 2019. Thereafter, & on the evidence of a
it was not clear when implementation of the updated policies would take effect.
Whilst the specific events that unfolded in retation to Mr Page on the morning of
23.3.18 may have been unforeseeable, the current arrangements/policies in
place for the receiving, utilising and storing of PODS at UHW, Cardiff, could give
rise to a risk of future deaths in a variety of different ways.
Once completed the exercise of implementing the new Policy & Code needs to
be thorough and extensive to ensure that all doctors & nurses throughout the
Cardiff & Vale University Health Board (whether full time, part-time or
Agency/locum) not only are aware of the revised Policy/Code, but clear on its
interpretation//requirements.
ACTION SHOULD BE TAKEN
(2
—
3
pod
(4
peor)
(5
—
In my opinion action should be taken to prevent future deaths and | believe you and your
organisation 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 7" January 2019. |, 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
I have sent a copy of my report to family who may find it useful or of interest.
Health inspectorate Wales, Welsh Government, HE Medica Director
of Cardiff and Vale Health Board.
| 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.
12" November 2018 SIGNED:
2
See every Prevention of Future Deaths report matching Hospital Death (Clinical Procedures and medical management) related deaths, and how often a new one appears.
What would an alert for this have sent me? Search the full text
Free to try — the preview shows the real matches and how many arrived in the last 12 months. Your first email alert is free.
These reports are published by the Chief Coroner's office at judiciary.uk and are © Crown copyright. The text here is reproduced from the published PDF so it can be searched. If something on this page is wrong, or you are a person named in it and want it reviewed, email drcjar@gmail.com and we will act promptly.