Prevention of Future Deaths reports · 2019
Regulation 28 report to prevent future deaths, reference 2019-0403, written 28 Nov 2019. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 28 Nov 2019 |
|---|---|
| Reference | 2019-0403 |
| Deceased | Thomas Wedrychowski |
| Coroner | Nicholas Rheinberg |
| Coroner area | Wiltshire and Swindon |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths · Mental Health related deaths |
| Organisation named | Avon and Wiltshire Mental Health Partnership NHS Trust |
| 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.
HM Assistant Coroner
for Wiltshire and Swindon
REGULATION 28 REPORT TO PREVENT FUTURE DEATHS
THIS REPORT IS BEING SENT TO:
(1) National Institute for Health and Care Excellence
10 Spring Gardens
London
SW1A 2BU
(2) Avon and Wiltshire Mental Health Partnership NHS Trust
Bath NHS House
Newbridge Hill
Bath
BA1 3QE
CORONER
(am Nicholas Rheinberg, Assistant Coroner for Wiltshire and Swindon
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
http://www.legislation.gov.uk/uksi/2013/1629/part/7/made
INVESTIGATION and INQUEST
On 31s January 2019 an investigation was commenced into the death of Thomas Wedrychowski
and thereafter an inquest was opened on 1S February 2019. On 28 November 2019 |
concluded the inquest. | found that the medical cause of death was
1a) diabetic ketoacidosis
1b medication induced diabetes mellitus (Type 1)
My conclusion was that the deceased died by misadventure
CIRCUMSTANCES OF THE DEATH
The deceased had been diagnosed as suffering from paranoid schizophrenia. For a number of
years he was prescribed anti-psychotic medication. Expert evidence at the inquest was to the
effect that the medication had caused the deceased to develop diabetes and that such causation
was both a direct consequence of taking anti-psychotic medication and also indirect in that the
medication contributed to the deceased becoming morbidly obese.
CORONER’S CONCERNS
At both primary and secondary health levels it appeared to have been the view that following
initial titration and a period of regular checks, annual monitoring for signs of the development of
diabetes should be carried out annually as recommended in NICE guideline CG178. However,
expert evidence at the inquest suggested that in cases of individuals with a higher risk of
developing diabetes, more regular checks were called for. Further there was evidence to the
effect that the results of relevant physical healthcare checks had not been shared between
primary and secondary healthcare providers. Thus:
(1) | draw to the attention of the National Institute for Health and Care Excellence their
guidance CG178 and specifically clause 1.3.6.4 thereof and ask them to consider
Wiltshire & Swindon Coroner's Office, 26 Endless Street, Salisbury, Wiltshire, SP1 1DP
Tel 01722 438900 | Fax 01722 332223
whether to the directive for an annual test of inter alia HbA‘1c, there might be added the
words:
“or more frequently in those who have a higher baseline risk for the development of
diabetes’.
| draw to the attention of Avon and Wiltshire Mental Health Partnership NHS Trust with
reference to their planned review of their document entitled “Medicines Guideline:
Monitoring psychotropic medication” my first paragraph addressed to the National
Institute for Health and Care Excellence and ask them to consider adding similar
wording to their recommendations with regard to annual review appearing at page 4 of
the present document.
Secondly, i ask the Trust to consider adding advice in the document to the effect that
when a patient is prescribed anti-psychotic medication contact be made with the
patient’s GP practice (a) informing them of this fact (b) requesting communication
thereafter of any physical health findings that might indicate serious side-effects or
potential side-effects of the drugs and (c) communicating any relevant physical health
findings to the GP practice as well as mental health findings.
(2
~~
6 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.
7 YOUR RESPONSE
You are under a duty to respond to this report within 56 days of the date of this report, namely by
25th January 2020. |, the assistant 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
lam sending a copy of my report to the Chief Coroner, the Family of the deceased, |
and Rethink Mental Iliness.
| 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.
9 Dated 28"-Novembe
Signature
Wiltshire & Swindon Coroner's Office, 26 Endless Street, Salisbury, Wiltshire, SP1 1DP
Tel 01722 438900 { Fax 01722 332223
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