Prevention of Future Deaths reports · 2020
Regulation 28 report to prevent future deaths, reference 2020-0038, written 25 Feb 2020. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 25 Feb 2020 |
|---|---|
| Reference | 2020-0038 |
| Deceased | Elaine Renshaw |
| Coroner | Alison Mutch |
| Coroner area | Greater Manchester South |
| 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: The Chief Executive of the Care Quality
Commission (CQC)
1
| CORONER
1am Alison Mutch, Senior Coroner, for the Coroner Area of Greater Manchester
South
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
INVESTIGATION and INQUEST
On 9" July 2019, | commenced an investigation into the death of Elaine
Renshaw. The investigation concluded on the 6" January 2020 and the
conclusion was one of Accidental Death. The medical cause of death was 1a)
Myocardial infarction, on a background of drug toxicity.
. CIRCUMSTANCES OF THE DEATH
Elaine Rose Renshaw worked at a care home and was found
unresponsive at her home address. She was resuscitated by
paramedics and taken to Tameside General Hospital. At Tameside
General Hospital attempts to reverse the effects of morphine
continued. They were unsuccessful and she continued to deteriorate.
On 8" July 2019, she died at Tameside General Hospital.
The care home where she worked identified that checks on controlled
drugs had not been accurate and controlled drugs had been incorrectly
accounted for.
Blood samples taken by the hospital were analysed. The concentration
of total morphine (that is morphine itself and morphine metabolites) in
her blood sample was within the range encountered in individuals
receiving morphine chronically (e.g. for palliative care). However, it
was equally within the range encountered in fatalities associated with
use of morphine even in chronic and therefore tolerant users.
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
!
I
{
|
is taken. In the circumstances, it is my statutory duty to report to you. ]
The MATTERS OF CONCERN are as follows. —
]
During the course of the inquest evidence was given that controlled drug checks
| processes had been such that it was not easily identified that drugs were not
| accounted for e.g. Stock sheets were inaccurate. The home in question had
tightened up its processes since the incident. However the inquest heard that
this issue may well arise in the future in other care/nursing home settings as
there is no clear process for handling/recording the use of controlled drugs.
6 T 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 21* April 2020. |, the coroner, may extend the period.
Your response must contain details of action taken or proposed to be taken, H
setting out the timetable for action. Otherwise you must explain why no action is |
proposed.
‘8 | COPIES and PUBLICATION
| |
| | have sent a copy of my report to the Chief Coroner and to the following
Interested Persons namely a husband of the deceased; 2)
Manchester City Council, who may tind If useful or of interest.
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. |
|
——
9 | Alison Mutch OBE
HM Senior Coroner
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