Prevention of Future Deaths reports · 2019
Regulation 28 report to prevent future deaths, reference 2019-0348, written 23 Oct 2019. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 23 Oct 2019 |
|---|---|
| Reference | 2019-0348 |
| Deceased | KennethDaly |
| Coroner | Catherine McKenna |
| Coroner area | Manchester North |
| Category | Alcohol, drug and medication related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
Coroner ME Hassell
HM Senior Coroner
Inner North London
REGULATION 28: REPORT TO PREVENT FUTURE DEATHS
THIS REPORT IS BEING SENT TO:
Clinical Director – St Bartholomew’s Hospital
Bart’s Health NHS Trust
Ground Floor,
Pathology and Pharmacy Building,
The Royal London Hospital,
80 Newark Street,
London,
E1 2ES
1
CORONER
I am: Assistant Coroner Sarah Bourke
Inner North London
Poplar Coroner’s Court
127 Poplar High Street
London
E14 0AE
2
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.
3
INVESTIGATION and INQUEST
On 10 December 2018, Senior Coroner Mary Hassell commenced an
investigation into the death of Kenneth John Daly aged 51 years. The
investigation concluded at the end of the inquest which was conducted by me
on 3 October 2019.
The conclusion of the inquest was that Mr Daly’s death was drug related.
The medical cause of death was:
1a multi-drug toxicity (Morphine, Dihydrocodeine, Codeine)
My short form conclusion was that:
“Mr Daly had longstanding problems with chronic back pain and anxiety. He was
prescribed multiple medications for this. Following review by pain management
specialists, it was decided that Mr Daly’s opioid medications would be reduced
to Morphine and Co-Codamol. However, he continued to be issued with
Dihydrocodeine prescriptions. Mr Daly overdosed on Morphine, Dihydrocodeine
and Codeine which was taken alongside prescribed Pregabalin and
benzodiazepine medication. Mr Daly was found deceased at his home on 4
December 2018.”
4
CIRCUMSTANCES OF THE DEATH
Kenneth Daly had problems with chronic pain in his lower back and legs
following an accident in 2000. He also had peripheral neuropathy, degenerative
disc disease, coronary artery disease and anxiety. Pain had a substantial impact
on Mr Daly’s quality of life and affected his ability to undertake activities of daily
living.
Mr Daly had been using Fentanyl patches (100 mcg/hour) for pain relief. He
wanted to stop using Fentanyl because of its impact on his quality of life and
memory. His GP had reduced the dosage to 75 mcg/hour. Mr Daly then noted
that his physical function had deteriorated. Mr Daly was also prescribed
Dihydrocodeine, Amitriptyline, Pregabalin and Tramadol for pain relief and
Venlafaxine, Olanzapine, Diazepam and Temazepam for his mental health. Mr
Daly was known to change the amounts of medication that he took depending
on how he felt at particular times. His GP decided to refer Mr Daly to pain
management specialists in 2017 for guidance on pain management with a
particular intention of reducing the use of opioid medications.
In January 2018, the Consultant in Anaesthesia and Pain Management initially
recommended reducing Fentanyl further to 50 mcg/hour and additionally
prescribing Tapentadol. He was also referred for physiotherapy. Mr Daly did not
find the changes to medication helpful and continued to use Dihydrocodeine
and Tramadol. In July 2018, Mr Daly attended a further appointment with his
Consultant at the medication management clinic. It was noted that he reported
high levels of pain, anxiety and depression and low levels of health related
quality of life. It was decided to stop Fentanyl altogether and start Morphine
Sulphate MR 60mg twice per day with Co-Codamol 30/500mg for breakthrough
pain. The pain management specialist’s view was that no other opioids were to
be taken once Morphine Sulphate and Co-Codamol had been prescribed but
that prescribing of Pregabalin could continue.
Mr Daly’s GP continue to issue prescriptions for Dihydrocodeine and Tramadol
at reduced quantities from the amounts issued in the past. In the later part of
2018, his GP also referred him to see specialists as he reported having a number
of falls. The cause of the falls had not been identified at the time of Mr Daly’s
death.
On 4 December 2018, Mr Daly was found dead at his home. Toxicology analysis
found Morphine, Dihydrocodeine, Codeine, Pregabalin, Diazepam, Temazepam,
Paracetamol, Venlafaxine, Amitriptyline and Olanzapine in Mr Daly’s system.
From the toxicology analysis, it is evident that Mr Daly had taken more than the
prescribed dose of Morphine, Dihydrocodeine, Pregabalin and Co-Codamol
prior to his death.
The Toxicologist’s evidence was that Morphine, Dihydrocodeine and Codeine all
belong to the same class of drugs and when taken in combination, their effects
are additive. One of the main side effects of opiates is respiratory depression
i.e. a suppression of the body’s ability to breathe which can be potentially fatal.
Pregabalin can increase the respiratory depressant effects of opioid
medications. Diazepam and Temazepam can also enhance the respiratory
depressant effects of opioid medications.
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 could 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 oral evidence, the Consultant stated that no other opioids were to be
taken once Morphine Sulphate and Co-Codamol had been prescribed
but that prescribing of Pregabalin could continue. She set out her advice
in a letter to Mr Daly’s GP dated 11 July 2018. The letter clearly stated
that Fentanyl and Tapentadol should be stopped and Morphine sulphate
(MST) 60mg started. The advice regarding the prescribing of pain
relieving medications other than Fentanyl and Tapentadol is less clear. In
relation to Dihydrocodeine and Tramadol it is stated that “He can
continue using the Dihydrocodeine and very rarely Tramadol until he sees
you for his next prescription. Together with the MST, I would recommend
to allow him Co-Codamol 30/500mg 2 tablets up to four times a day…”.
Following receipt of the letter, Tramadol and Dihydrocodeine continued
to be issued by the GP practice albeit at lower quantities than previously
prescribed. The GP did not seek any further guidance regarding the
advice given in the letter of 11 July 2018 from the Consultant.
2) Mr Daly was a patient that was known to adjust his pain medication
without seeking guidance from his GP. Whilst Mr Daly was copied in to
the letter sent to his GP on 11 July 2018, he was not given any written
guidance regarding his pain relief and the use of other medications (such
as benzodiazepines) that was tailored to his needs as a patient.
Specifically, he was not given any written advice regarding the risks of
using multiple opioid medications in combination.
6
ACTION SHOULD BE TAKEN
In my opinion action should be taken to prevent future deaths and I believe you
and your organisation have the power to take such action.
7
YOUR RESPONSE
You are under a duty to respond to this report within 56 days of the date of this
report, namely by 18 December 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.
8
COPIES and PUBLICATION
I have sent a copy of my report to the Chief Coroner and to the following
Interested Persons
a)
b)
I 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.
Sarah Bourke
Assistant Coroner
23 October 2019
REGULATION 28: REPORT TO PREVENT FUTURE DEATHS (1) REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: The Chief Executive, Rochdale Borough Housing Limited, Sandbrook House, Sandbrook Way, Rochdale, OL11 1RY 1 CORONER lam Catherine McKenna, Assistant Coroner for the Coroner area of Manchester North 2 CORONER’S LEGAL POWERS | make this report under paragraph 7, Schedule 5, of the Coroner's and Justice Act 2009 and Regulations 28 and 29 of the Coroners (Investigations) Regulations 2013 3 INVESTIGATION and INQUEST On the 5" March 2018, | commenced an investigation into the death of John Eric Graham 4 CIRCUMSTANCES OF DEATH Mr Graham was a tenant of Rochdale Borough Housing Limited. He was found dead at his home address on 26 February 2018. Post-mortem and Toxicology evidence suggested that ketoacidosis coupled with carbon monoxide toxicity caused his death. Upon further exploration of the evidence, carbon monoxide was excluded from the cause of death and | concluded that he died as a result of natural causes. However, the evidence that | heard during the course of the inquest was that carbon monoxide detectors are not routinely installed in homes rented by Rochdale Borough Housing Limited. 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:- Carbon monoxide detectors are not routinely installed in residential accommodation rented by Rochdale Borough Housing Limited which, if unremedied, creates a risk of future deaths. 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and | believe each of you respectively 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 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 | have sent a copy of my report to the Chief Coroner and to the following Interested Persons namely:- 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 from. He may send a copy of this report to any person who he believes may find it usefulor 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. Date: 9/11/18 Signed: Coleone
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.
4 ROCHDALE BOROUGHWIDE HOUSING LIMITED LEGAL TEAM Sandbrook house Sandbrook Park TOGETHER Sandbrook Way D LIVING | Rochdale ; OL11 1RY Telephone: 01706 273842 HM Coroners Court a Ref: Phoenix Centre . L/Cpl Stephen Shaw MC Way Cu Ree to: DL/MISC 161 Heywend Extension: , OL10 1LR vane Email: Website: www.rbh.org.u Po Date: 26 March 2019 Dear Sirs Re Death of John Eric Graham (MT) This response is prepared in order to comply with the Notice of HM Coroner pursuant to Regulation 28 of the Coroners (Investigations) Regulations 2013 (“The Regulations”). At the inquest of Mr Graham, the Assistant Coroner expressed concern that carbon monoxide detectors are not routinely installed in residential accommodation rented by Rochdale Boroughwide Housing Ltd which, if not remedied, creates a risk of future deaths. Response The Smoke and Carbon Monoxide Alarm (England) Regulations 2015 only require private landlords to install carbon monoxide detectors and Registered Providers are specifically excluded from the regulations. Further, the installation will only take place if there are rooms containing solid fuel burning appliances and such detectors are not required when there are only gas burning appliances installed. This is re-iterated by the Building Regulations, Part J, which requires that when a new or replacement solid fuel appliance is installed a carbon monoxide detector is fitted. However, no mention is made of gas appliances. On the 30th April 2018 the Government announced a review into the rules that require carbon monoxide alarms to be fitted in homes across England. The review is considering whether there should be a blanket requirement to install alarms for all methods of heating, including gas and oil appliances. Until the outcome of that review is known it would not be prudent to consider a wholesale installation programme in the absence the detailed requirements that such a recommendation would bring. For example, the most recent changes in Scotland will require smoke and carbon monoxide detectors in specific locations and of specific types. They will also need to be hard wired when those regulations come into force in Scotland in February GET ITOUCH Follow rbhousing: Visit us at rbh.org.uk or talk to us on wl f | | You | 0800 027 7769 or (01706) 274100 mm Rochdale Boroughwide Housing Limited is a charitable community benefit society. FCA register number 31452 R. Registered Office: Sandbrook House, Sandbrook Way, Rochdale OLII IRY. Registered as a provider of social housing. RSH Register number 4607. Rochdale Boroughwide Housing will continue to monitor the outcome of the current review and any recommendations which follow will be considered for implementation. Yours faithfully Solicitor Rochdale Boroughwide Housing Limited
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