Prevention of Future Deaths reports · 2019
Regulation 28 report to prevent future deaths, reference 2019-0228, written 1 Jul 2019. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 1 Jul 2019 |
|---|---|
| Reference | 2019-0228 |
| Deceased | Andrew McCall |
| Coroner | Andrew Barkley |
| Coroner area | Stoke-on-Trent & North Staffordshire |
| 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
THIS REPORT IS BEING SENT TO:
1. Mr Simon Stevens
Chief Executive NHS England
PO Box 16738
Redditch
897 9PT
CORONER
| am Andrew Barkley Senior Coroner for Stoke-on-Trent & North Staffordshire
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.
http://www. legislation. gov.uk/ukpga/2009/25/schedule/5/paragraph/7
htto://www. legislation.gov.uk/uksi/2013/1629/part/7/made
INVESTIGATION and INQUEST
On 24" September 2018 | commenced an investigation into the death of Andrew Peter McCall. The
investigation concluded at the end of the inquest on 27th June 2019. The conclusion of the inquest was
that the death was drug related. The deceased was found face down ati.
lon 18th September 2018 after concern was raised for his welfare. The
accommodation was "supported living accommodation” for vulnerable individuals. The deceased had a
history of drug misuse and was on a methadone programme. He was also prescribed pregabalin by his
GP. The cause of death given after a post mortem examination was :-
1a Gastric aspiration.
1b Pregabalin and methadone use.
1ic-
Il-
CIRCUMSTANCES OF THE DEATH
The deceased was found face down unresponsive in his supported living accommodation on 18"
September 2018 after concern was raised for his welfare. He had a history of difficulties with illicit drugs
and was on a Methadone prescription which was managed by the “One Recovery Clinic’. He was also
prescribed a number of medications by his GP. A Post Mortem examination together with toxicology
provided that he had died from the effect of gastric aspiration due to Pregabalin and Methadone use.
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 evidence revealed a clear pattern of “medication seeking behaviour” with his GP to obtain additional
amounts of Pregabalin. The evidence also showed that his GP was not aware that he was on a current
Methadone script. The “One Recovery” clinic operated a system which was dependent upon the service
user declaring which GP practice they were registered with. This was not checked or verified
independently and therefore concern must exist that the GP may be unaware that a patient is on an
opiate replacement regime, prescribed by another organisation, and may therefore prescribe
medications which may not be suitable and which may potentially be harmful. It is suggested that, where
patients are prescribed medication as part of “opiate replacement therapy”, GPs have the means to
check the details and the organisation providing such a service. This puts in place a more robust system
to ensure that the current GP is fully aware of the treatment programme.
ACTION SHOULD BE TAKEN
tn my opinion action should be taken to prevent future deaths and | believe you or your organisation has
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 30"
August 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
1 have sent a copy of my report to the Chief Coroner and to the following Interested Persons:
1. DE Wel! Street Medical Centre, Well Street, Cheadle, Staffs, ST10 1£Y
Keoghs Solicitors {instructed by Rethink Mental Illness
One Recovery
2
3.
4. EERE (daughter of the deceased)
5
6.
. iimineete (brother of the deceased)
. SE father of the deceased)
lam 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.
01/07/2019
Signature.
e4on-Trent & North Staffordshire
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.
Professor Stephen Powis
National Medical Director
Skipton House
80 London Road
SE1 6LH
26th September 2019
Andrew Barkley
Senior Coroner
Stoke on Trent and North
Staffordshire
Coroners Chambers
547 Hartshill Road
Stoke on Trent
ST4 6HF
Dear Mr Barkley,
Re: Regulation 28 Report to Prevent Future Deaths – Andrew Peter McCALL -
18/9/2018
Thank you for your Regulation 28 Report (hereinafter the ‘report’) dated 1 July 2019
concerning the death of Andrew Peter McCall on 18th September 2018. Firstly, I
would like to express my deep condolences to Mr McCall’s family.
Your report identifies that the recent inquest concluded that Mr McCall’s death was
drug related with the cause of death given as: (1a) Gastric Aspiration, (1b)
Pregabalin and Methadone Use.
Following the inquest you now raise concerns in your report for NHS England to
consider regarding the communication between One Recovery Clinic, and Mr
McCall’s GP. You noted that One Recovery Clinic relied on the service user to
provide details of their GP, and that this information was not then checked or
verified.
Therefore you have identified that it could be possible for service users to be
prescribed an opiate replacement programme, without their own GP being made
aware of this, increasing the risk of inappropriate, unsuitable or harmful medication
being prescribed.
You have recommended that a process be put in place to ensure that GPs are
made aware when another organisation are managing an opiate replacement
programme for one of their registered patients.
In this case the service is provided by One Recovery Clinic, in conjunction with
North Staffordshire Combined Healthcare NHS Trust. The lead provider is
Addiction Dependency Solution. Substance misuse services are commissioned by
the Local Authority, not NHS England or the Clinical Commissioning Group.
One Recovery is the provider of drug and alcohol community services in
Staffordshire and is commissioned by Staffordshire County Council
The commissioner contact details for the service is therefore Tony Bullock,
NHS England and NHS Improvement
(anthony.bullock@staffordshire.gov.uk), Lead Commissioner - Public Health and
Prevention Health and Care Staffordshire County Council.
Although NHS England is neither the commissioner or regulator of these services,
and have no direct responsibility for them, we recognise the importance of the
concerns you have raised, and are taking the following action:
Dr Kenneth Deacon, Medical Director for System Improvement and Professional
Standards (Midlands) will:
By 30th September 2019
By 30th September 2019
By 30th September 2019
Make contact with the service lead from Addiction
Dependency Solutions, and ask that they:
-
review their processes for collecting GP data;
- verify GP data provided by service users (to
ensure information is sent to the correct
practice); and
review processes for ensuring that relevant
information is reliably and consistently shared
with the registered GP.
-
Share the above communication with the Local
Authority, to allow them to monitor as part of their
commissioning responsibility for this service.
Write to all GP practices within Staffordshire:
- making them aware of the inquest findings,
-
and the risks this highlights;
importance of
the
reminding
considering whether other agencies might be
prescribing opiate replacements; and
them of
- asking them to alert the clinic directly if they
receive information relating to a patient not
registered at the practice (so the correct
practice can be identified quickly).
Thank you for bringing this important patient safety issue to my attention and
please do not hesitate to contact me should you need any further information.
Yours sincerely,
Professor Stephen Powis
National Medical Director
NHS England and NHS Improvement
NHS England and NHS Improvement
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