Prevention of Future Deaths reports · 2018
Regulation 28 report to prevent future deaths, reference 2018-0409, written 31 Dec 2018. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 31 Dec 2018 |
|---|---|
| Reference | 2018-0409 |
| Deceased | Janice Davies |
| 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 | 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.
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:
1. The Chief Executive Cwm Taf University Health Board
CORONER
{ am Graeme Hughes, Area Coroner, for the coroner area of South Wales Central
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
| commenced an investigation on the 315 October 2018 into the death of Janice Mary
Davies. Investigation concluded at the end of the inquest on 14% December 2018. The
conclusion was Drug Related (prescription) Accidental death and the medical cause of
death was 7a. Morphine Toxicity and Bilateral Rib Fractures 1b. Mechanical Fall 2.
Chronic Obstructive Pulmonary Disease and Chronic Kidney Disease
CIRCUMSTANCES OF THE DEATH
On 19.4.18 Janice Davies fell out of bed at home sustaining fractured ribs. She attended
the Royal Glamorgan Hospital that day, given 2 x 5mi doses of oramorph, prescribed 4 x
10mls oramorph daily - a supply of around 2 weeks and then, discharged home. She
was unable to tolerate the oramorph after around lunchtime on 20.4.18 and following
medical advice from her GP, switched to her usual pain killing medication - co-codamol
and oxyNorm. Sometime thereafter, the concentration of morphine in her blood reached
a toxic level, likely contributed to by her undiagnosed chronic kidney disease
(discovered at post mortem examination). This has likely caused respiratory depression
which, on the background of impaired lung function has led to her death at home at
MI, 2 cary nous 214.18.
In broad terms, the Inquest focused upon:-
a. The appropriateness of the care provided to the deceased at Royal Glamorgan
Hospital on 19.4.18 & from her GP on 20.4.18
The dosages of oramorph given & prescribed to the deceased at Royal
Glamorgan Hospital.
The observations of the deceased on 19.4.18
The discharging of the deceased on 19.4.18
The content of the advice (by telephone) given by her GP on 20.4.18 regarding
her toleration of oramorph
The causal effects of the dosages of oramorph in the setting of the
posthumously identified chronic kidney disease
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) There was an absence of documented (despite indicated) observations of the
deceased post her doses of oramorph at around 13:55 hrs & 15.40 hrs on
19.4.18.
(2) There was an absence of an updated & documented pain score prior to
discharge. Most significantly, this, on the evidence of REE would have
been desirable/required to inform the prescribing clinician, MEEMMBof the
most appropriate prescription of oramorph to be given to the deceased upon
discharge.
Most significantly, there appeared, on the evidence, to be an absence of formal
guidance or instruction~ written or otherwise to clinicians in the Accident &
Emergency Department regarding the prescribing of oramorph to discharging
patients. This would appear then to give rise to potential inconsistencies in the
prescribing of oramorph to discharging patients. Not only in terms of prescribed
dosages, but also in respect of the extent of the supply. The deceased was
prescribed 40 mis per day & given a supply fasting two weeks. SR
evidence was that in the absence of clear evidence as to the deceased's
tolerance to morphine, he would be uncomfortable with this dosage & supply
His evidence was that a prescription of 20 mis per day, & a supply for 5 days
(then review by GP if symptoms persisted/to assess the patient's reaction to the
h} was more appropriate in the circumstances
ACTION SHOULD BE TAKEN
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 25" February 2019. 1, 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 UC the deceased’s husband,
Eglwysbach Medical Practice - the deceased's GP practice, Welsh Government, Mr
Kamal Assad, Medical Director Cwm Taf University Health Board & Health Inspectorate
Wales 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.
318* December 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.
Your Ref/eich cyf
Our Ref/ein cyf 18/2836/INQ
g : G IG Bwrdd lechyd Prifysgol Date/dyddiad 8 aun
Tel/ffén
“Hye NHS Sty) Taf Fax/FFacs 01443 744889
) University Health Board Email/ebost Kellie Jenkins-Forrester@wales nhs uk.
Dept/adran Patient Care & Safety
Private & Confidential
Mr Graham Hughes
South Wales Area Coroner
Pontypridd Coroners Court
Court House Street
Pontypridd
CF37 1J]W
Dear Mr Hughes
RE: Regulation 28 — Janice Davies
Thank you for the correspondence in relation to the above Regulation 28 received on 28th
December 2018, which details the areas of concern following the conclusion of the inquest
held 14" December 2018.
Please be assured that the Health Board has taken this matter extremely seriously, has learnt
lessons following the investigation and the matters raised at the inquest into the
circumstances of Mrs Davies’ death. Comprehensive and robust action has been taken to
minimise the risk of any recurrence.
1. Action taken to plan and monitor improvements
A corrective Action Plan for Improvement has been developed which reflect the
concerns identified within the Regulation 28 Report.
2. Actions Implemented
A number of actions have been taken forward by the Health Board, the progress
with these actions is reflected in the attached action plan which include:
1) The Registered nurse to personally reflect on the care given and the importance of
undertaking observations and pain assessment following the administration of opioid
medication.
2) A Standard Operating Procedure has been implemented to advise on the appropriate
use of oral opioid medication in acute pain. A copy is attached.
3) This case has been discussed in the Rapid Response to Acute Illness (RRAILS) on
25" January 2019 and will be reviewed in the next RRAILS on 29" Aprif 2019.
4) The departmental manager to ensure pain score audits are undertaken.
Sees
Return Address: Cwm Taf University Health Board, Headquarters, Navigation Park, Abercynon, CF45
4SN ;
Chair { Cadeirydd; Professor Marcus Longley Chief Executive / Prif Weithredydd: Mrs A Williams
Cwm Taf Unwersity Health Board is the operational name of the Cwm Taf University Health Board/Bwrde lechyd Prifysgol Cwm Tal yw enw gwesthredot
Bwrdd lechyd Prifysgol Cwm Taf
I sincerely hope that this information and enclosed Action Plan will reassure you that
the Health Board has learnt important lessons from the investigation into the care
provided to Mrs Davies and that effective action has now been taken to prevent further
deaths.
I would like to convey once again my deepest sympathy and sincere apologies to Mrs
Davies’ family for the failings identified.
Sn Sekt
Mrs Allison Williams
Chief Executive Officer
Enc
EE
Return Address: Cwm Taf University Health Board, Headquarters, Navigation Park, Abercynon, CF45
4SN
Chair / Cadeirydd; Professor Marcus Longley Chief Executive / Prif Weithredydd: Mrs A Wilhams
Cwm Taf University Health Board is the operational name of the Cwm Taf University Health Board/Bwrdd lechyd Prifysgol Cwm Taf yw enw gweithredot
Bwedd lechyd Prifysgol Cwm Taf
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