Prevention of Future Deaths reports · 2019
Regulation 28 report to prevent future deaths, reference 2019-0489, written 4 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 | 4 Oct 2019 |
|---|---|
| Reference | 2019-0489 |
| Deceased | Michael Lobban |
| Coroner | Russell Caller |
| Coroner area | London Inner (West) |
| Category | Alcohol, drug and medication related deaths |
| 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.
REGULATION 28: REPORT TO PREVENT FUTURE DEATHS
[REGULATION 28 REPORT TO PREVENT FUTURE DEATHS
THIS REPORT IS BEING SENT TO:
1. The General Pharmaceutical Council, 25, Canada Square, London, E14 5LQ.
2. Boots UK Ltd., Head Office, D90, 1, Thane Road, Nottingham, Nottinghamshire, NG2
SAA.
Fy the Professional Standards Officer, Boots UK, D90 EFO8, 4,
Thane Road, Nottingham, Nottinghamshire, NG90 3SJ.
4. The Senior Clinical Advisor, Controlled Drugs, NHS England, c/
Controlled Drugs Accountable Officer, NHS England & NHS Improvement, 2°¢ Floor,
Wellington House, Waterloo, London, SE1 8UG.
Chief Coroner of England & Wales, His Honour Judge Mark Lucratt
oyal Courts of Justice, Strand, London, WC2A 2LL.
CORONER
lam Russell A Caller, HM Assistant Coroner, for the Coroner Area of Inner London West
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 Tuesday 10th September 2019 Russell Caller, Assistant Coroner heard the inguest
of Michael Lobban who was found dead at his home
GD Vonday 23” October 2017
Medical Cause of Death
{ (a) Mixed Drug Consumption
How, when and where and in what circumstances the deceased came by his
death:
Michael Lobban was on a prescription of 5mg Methadone tablets and was required to
pick up his prescription form Boots, Queensway London Branch on a regular basis.
| Michael Lobban was known to the staff at this Boots branch. On Thursday 19" October |
2017 Michael Lobban picked up 68 x 5mg Methadone tablets in accordance with his |
prescription. The following Thursday 26" October 2017 during a Controlled Drug
—
Running Balance audit check by Boots, Queensway Branch there was a disparity in the
numbers of Methadone tablets. It transpires there were 51x 5mg methadone tablets
missing.
On ihe Monday prior to this audit check on Monday 23 October 2017 ( 3 days before
Boots discovered the disparity of 51 x 5mg of methadone tablets) Michael Lobban was
found dead in his home at 31c Talbot Road London W2 5JG with, inter alia, an
excessive amount of methadone in his blood ( 0.56 ug/ml in his blood) which amounts to
a significant overdose of methadone.
There were other drugs found in Michael Lobban’s body in the toxicology report taken
after death.
Conclusion as to the death:
Drug Related
—
|
CIRCUMSTANCES OF THE DEATH
For many years Michael Lobban had been suffering from serious mental health issues
and had been under the Drug and Alcohol Well-being Service (DAWS) for a number of
years.. He suffered from Drug dependency and mental iliness and had periods of
overdosing causing self-harm and there had been threats of suicide.
Michael Lobban was on a prescription of mg Methadone tablets and was required to
pick up his prescription form Boots, Queensway London Branch on a regular basis.
Michael Lobban was known to the staff at this Boots branch. On Thursday 19" October
2017 Michael Lobban picked up 68 x 5mg Methadone tablets in accordance with his
prescription. On the following Thursday 26" October 2017 during a Controlled Drug
Running Balance audit check by Boots, Queensway Branch there was a disparity in the
numbers of Methadone tablets. It transpires there were 51x 5mg methadone tablets
missing.
On the Monday prior to the audit check on Monday 23" October 2017 ( 3 days before
Boots discovered the disparity of 51 x 5 mg of methadone tablets) Michael Lobban was
found dead in his home with, inter alia, an excessive amount of methadone in his biood (
0.56 ug/ml in his blood) which amounts to a significant overdose of methadone.
There were other drugs found in Michael Lobban’s body in the toxicology report taken
after death.
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 fo you.
The MATTERS OF CONCERN are as follows. —
1. The investigation carried out by The Boots Company PLC into the disparity of
Methadone tablets on this occasion was siow and efforts to contact patients who
were regular prescription users of methadone was not fully followed through.
J
2. The audit checking of controlled drugs by The Boots Company PLC is not robust
in that there is no double check in place in relation to the audit checking
procedure followed by Boots.
3. There appears to be no physical check of the contents of prescription boxes |
when carrying out the audit of schedule 2 controlled drugs.
4. The General Pharmaceutical Council (‘The Council") being the Regulator of
Pharmaceutical industry in England and Wales does not have any reporting
requirements for pharmacies when discovering a discrepancy in schedule 2
controlled drugs. Moreover there appear to be no investigative powers by The
Council where it discovers a disparity of these controlled drugs and as a
consequence there are no sanctions in circumstances where pharmacies have
mislaid drugs during the course of their handling of controlled drugs.
ACTION SHOULD BE TAKEN
in my opinion action should be taken to prevent future deaths and | believe you AND/OR
your organisation have the power to take such action, It is for each addressee to
respond to matters relevant to them.
1. The Council should implement industry wide policies and reporting requirements by
pharmaceutical companies in relation to Drug Discrepancy for all Controlled drugs and
2.The Boots Company PLC should review its processes and procedures in dealing with
occurrences of drug disparity for controlled drugs which should include:
A). make robust rules to ensure contact with a patient or third party that could be
affected by a disparity of controlled drugs.
B) ensure the physical checking of the contents of prescription boxes for controlled
drugs is robust and secure
C) to implement a second check in relation to the controlled drug register for Controlled
drugs.
YOUR RESPONSE
You are under a duty to respond to this report within 56 days of the date of this report. |,
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.
COPIES and PUBLICATION
| have sent a copy of my report to the Chief Coroner and to the following Interested
Persons |
i, The General Pharmaceutical Council, 25, Canada Square, London, Ei4 5LQ. |
2. Boots UK Ltd., Head Office, D90, 1, Thane Road, Nottingham, Nottinghamshire, NG2
SAA.
3. ee; Professional Standards Officer, Boots UK, D90 EFO8, 1,
Thane Road, Nottingham, Nottinghamshire, NG90 3SJ.
4. The Senior Clinical Advisor, Controlled Drugs, NHS England, c/o|
Controlled Drugs Accountable Officer, NHS England & NHS Improvement, 2°? Floor,
Wellington House, Waterloo, London, SE1 8UG.
5 The Chief Coroner of England & Wales, His Honour Judge Mark iucrar i
oyal Courts of Justice, Strand, London, WC2A 2LL.
The Chief Coroner may publish either or bath 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 Assistant Coroner, at the time
of your response, about the release or the publication of your response by the Chief
Coroner.
4" October 2019
Del les
Russell Caller
HM Assistant Coroner
Inner West London
Westminster Coroner's Court
65, Horseferry Road
London
SW1P 2ED
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