Prevention of Future Deaths reports · 2019
Regulation 28 report to prevent future deaths, reference 2019-0421, written 10 Dec 2019. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 10 Dec 2019 |
|---|---|
| Reference | 2019-0421 |
| Deceased | Brenda Drew |
| Coroner | Rachael Griffin |
| Coroner area | Dorset |
| Category | Alcohol, drug and medication 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 (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. Mr Paul Bennett, Chief Executive Officer of the Royal Pharmaceutical Society, 66 East Smithfield, London, E1W 1AW CORONER Iam Rachael Clare Griffin, Senior Coroner, for the Coroner Area of Dorset 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 On the 11 April 2019, an investigation was commenced into the death of Brenda Anne Drew, born on the 16" April 1947. The investigation concluded at the end of the Inquest on the 27" November 2019. The Medical Cause of Death was: la Fatal intoxication with Morphine The conclusion of the Inquest was accident. CIRCUMSTANCES OF THE DEATH On the 10 November 2018 the deceased, who was partially sighted, fell at her home address and sustained a right fracture of the distal end of the radius. Following attendance at Poole Hospital, Poole, she was prescribed Oramorph upon discharge for pain relief. This continued to be prescribed by her GP without review until the 29° March when she was told to stop taking it. On the 6" April 2019 she was found in a collapsed and unresponsive condition at her home address. Toxicology testing following her death revealed a fatal level of morphine in her blood. 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. During the inquest evidence was heard that: Mrs Drew was prescribed 100ml of Oramorph by the hospital for pain relief following her fracture. At that time she was also prescribed other medications on a routine basis by her GP for unrelated conditions. These other medications were on repeat prescription. These prescriptions were requested on her behalf by Lloyds Pharmacy in Ashley Cross, Poole. The prescription requests were sent to her GP at Wessex Road Surgery, Poole who authorised the requests and then Lloyds pharmacy would prepare the medications for Mrs Drew. After her discharge from Hospital Mrs Drew, in addition to her routine prescriptions, began to receive 300ml of Oramorph on repeat prescription. She received these on 27.11.18, 18.12.18, 18.01.19, 24.02.12 and 20.03.19. Evidence given by her family at the Inquest was that she never requested these repeat prescriptions for Oramorph and was surprised to receive them. At the Inquest a GP from Wessex Road surgery gave evidence that the surgery had already identified that this should not have happened and that there had been no formal review at the surgery of the Oramorph prescription to Mrs Drew between 27 November 2018 and 29° March 2019 when she was advised by a GP to stop taking Oramorph. There had been an investigation about this by the Surgery and they were having a meeting on the 5 December 2019 when the processes surrounding this were to be discussed along with the implementation of new guidance regarding Oramorph. Evidence however was given by a 2 there was concern that Pharmacists seem to request repeat prescriptions for medications without seeking the views of patients. Mrs Drew’s family explained at the Inquest that she had not been asked about the continued prescription of Oramorph. There is therefore a risk that patients may have access to medications without requesting it, as occurred with Mrs Drew. It was explained at the Inquest that this is a common concern as it appears to occur regularly. 2. Ihave concerns with regard to the following: I am concerned that prescriptions are being requested from GPs by Pharmacists without consultations with patients or having been requested by patients. I would therefore request that consideration be given to providing guidance to all pharmacists in England and Wales that when making a request for a prescription to GPs, they should ensure the wishes of the patient are obtained, save in circumstances where this is not possible, such as where the patient lacks capacity. ACTION SHOULD BE TAKEN In my opinion urgent action should be taken to prevent future deaths and I believe you and/or 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, 4 February 2020. 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. COPIES and PUBLICATION I have sent a copy of my report to the Chief Coroner and to the following Interested Persons: (1) The family of Mrs Drew I have also sent a copy of my report to the following people who I believe have a sufficient interest in the contents of it: (1) ME essex Road Surgery, Lower Parkstone, Poole, BH14 8BQ (2) Lloyds Pharmacy, 10 Station Road, Parkstone, BH14 8UB Iam 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. Dated oe LaErAI. Rachael C Griffin 10 December 2019
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.
ROYAL P HAR MA C E U T l CAL 66 East Smithfield support@rpharms.com S$ 0 C l E TY London E1W 1AW www.rpharms.com T 0845 257 2570 Rachael C Griffin The Coroner’s Office for the County of Dorset Town Hall Bournemouth BH2 6DY 3 January 2020 Dear Rachael C Griffin RE: Brenda Anne Drew Deceased Thank you for your letter dated 10° December 2019 following the recent inquest into the death of Brenda Anne Drew. We would like to express our sincere condolences to Brenda Anne Drew's family. As you may know the Royal Pharmaceutical Society (‘RPS’) is the professional body for pharmacists and pharmacy in Great Britain, representing ail sectors of pharmacy. Our role is to lead and support the development of the pharmacy profession. We transferred our regulatory role to the General Pharmaceutical Council (‘GPhC’) in 2010, and they now regulate pharmacy and pharmacy professionals in Great Britain. Their contact details are: General Pharmaceutical Council, 25 Canada Square, London, E14 5LQ, phone: 0203 713 8000 and email: info@pharmacyregulation.org. You may wish to contact them separately if you haven't already done so. We understand the matters of concern which you have raised and are keen to assist where we can. Our observations on the concerns you have raised are as follows: Guidance for pharmacy teams Your letter recommended we produce guidance for pharmacists covering requests for prescriptions to GPs and we would like to confirm that we published guidance in this area in 2015. A copy is included with this response. Our guide is for pharmacy teams and covers the points raised in the report. There are sections on consent, pharmaceutical care and audit trail. The section on pharmaceutical care describes good practice: All people using the services are provided with high quality pharmaceutical care and can use their medicines safely and effectively People using these services (particularly delivery services) are more likely to have little, if any, personal contact with the pharmacy team or other healthcare professionals. They maybe housebound, disabled or elderly but deserve the same high quality pharmaceutical care provided to others. To achieve this consider: e — Confirming with the patient or carer whether the medicines are needed before re-ordering ¢ Whether the medication prescribed is still clinically appropriate at the time of supply and the risks of not supplying e¢ Whether a direct conversation, or face-to-face contact with the patient or carer is needed e Whether there are adherence or compliance issues ¢ When providing a repeat medication management service, the pharmacy team should take care to order medicines using an interval that takes into account the risk of prescribing changes, appropriate quantities, time for the clinic to process a request and a responsive service for patients e Checking that you have the correct contact details for the patient or carer. We will continue to help raise awareness and to encourage continuing and further adoption of the guidance by pharmacy teams. Patron: Her Majesty The Queen Chief Executive: Paul Bennett ROYAL | PHARMACEUTICAL | 66 East Smithfield T0845 257 2570 support@rpharms.com SOCIETY London E1W 1AW FF 020 7735 7629 www.rpharms.com An electronic copy of the guide is available from our website. https://Awww.rpharms.com/resources/toolkits/repeat-medication-management RPS Prescribing competency framework We updated and published a Prescribing Competency Framework for all prescribers in 2017 in collaboration with all prescribing professions across the UK. This framework sets out the competencies expected of all prescribers to support safe prescribing and one of the competencies covers repeat medicines. Competency 7 — prescribe safely states: Minimises risks to patients by using or developing processes that support safe prescribing particularly in areas of high risk (e.g. transfer of information about medicines, prescribing of repeat medicines). Our framework is available here https://www.rpharms.com/resources/frameworks/prescribers-competency-framework Guidance published by other pharmacy bodies The GPhC has also produced guidance on consent that could be applied to the ordering of medicines. This states: Pharmacy professionals have a professional and legal duty to get a person’s\consent for the professional services, treatment or care they provide, and for using a person’s information. https://www. pharmacyregulation.org/sites/default/files/in_practice- quidance_on consent may 2017 0.pdf. Thank you for bringing this to our attention and | hope our response has been helpful. Yours sincerely ere Patron: Her Majesty The Queen = Chief Executive: Paul Bennett
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