Prevention of Future Deaths reports · 2020
Regulation 28 report to prevent future deaths, reference 2020-0061, written 6 Mar 2020. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 6 Mar 2020 |
|---|---|
| Reference | 2020-0061 |
| Deceased | REDACTED |
| Coroner | R Brittain |
| Coroner area | Inner North London |
| Category | Alcohol, drug and medication related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 2 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
REGULATION 28: REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: 1. 2. : Director, Alcohol, Drugs & Tobacco, Health and Wellbeing Directorate, Public Health England - Wellington House, 133-155 Waterloo Road, London. SE1 8UG 80 London Road, London SE1 6LH , National Medical Director, NHS England - Skipton House, 1 CORONER I am R Brittain, Assistant Coroner for Inner London North. 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 died on 13 June 2019, aged 30 years, from the consequences of cocaine use, which resulted in a posterior stroke. I heard the inquest into his death on 22 November 2019 and recorded a narrative conclusion, as set out below: died from the consequences of cocaine use, which resulted in a posterior stroke. There were intervals to the treatment of this, although it is not possible to conclude that this contributed to his death. 4 CIRCUMSTANCES OF THE DEATH was admitted to Queen’s Hospital, Romford on 9 June 2019. The previous evening he had ingested cocaine and, in the early hours of 9th, he collapsed, unable to speak or move his left side. He was diagnosed with a basilar artery occlusion and underwent thrombolysis at 14.40 later that day. He was transferred to The National Hospital for Neurology and Neurosurgery shortly thereafter. A thrombectomy procedure was successfully carried out, also on 9 June. However, he suffered a further deterioration and was declared brainstem dead on 13 June 2019. 5 CORONER’S CONCERNS During the course of this 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 following the inquest were as follows: Concern 1, to be addressed by Public Health England 1. family raised concerns that the risk of stroke arising from cocaine use was not known to him nor his family members. They were concerned that future deaths could occur in similar circumstances and that there is limited public awareness of such risks. I share these concerns and ask that Public Health England consider this point. Concern 2, to be addressed by NHS England 2. I heard evidence during this inquest that the availability of thrombectomy is currently variable and dependent on geographical location and timing. I am concerned that this variation will mean that future deaths will occur in similar circumstances, unless access to thrombectomy services is improved. 6 ACTION COULD BE TAKEN In my opinion action could be taken to prevent future deaths and I believe that the addressees 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 1 May 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, Havering and Redbridge University Hospitals NHS Trust and University College London Hospitals NHS Foundation Trust. , Barking, I am also under a duty to send the Chief Coroner a copy of your responses. 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 Assistant Coroner R Brittain 6 March 2020
2 responses 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.
Dr R Brittain
Assistant Coroner for
Inner London North
Poplar Corners Court
127 Poplar High Street
London
E14 0AE
National Medical Director
Skipton House
80 London Road
SE1 6LH
15th July 2020
Dear Assistant Coroner Brittain,
Re: Regulation 28 Report to Prevent Future Deaths –
June 2019
- 13
Thank you for your Regulation 28 Report dated 6 March 2020 concerning the death
of
condolences to
on 13 June 2019. Firstly, I would like to express my deep
.
The regulation 28 report concludes
cocaine use which resulted in a posterior stroke.
death was a result of
Following the inquest, you raised concerns in your Regulation 28 Report to NHS
England regarding variable geographic and timing access to thrombectomy
services.
NHS England is rolling out access to thrombectomy nationally via specialised
neuroscience centres over a 5-year period. This commenced in April 2017 with the
mapping of services against a specification. Neuroscience centres were asked to
develop implementation plans that include being able to move to a fully staffed 24/7
service over 5 years. It is recognised that there is currently an insufficient number of
suitably qualified medical teams to support the expansion of thrombectomy services
and this is a rate-limiting factor in terms of being able to provide comprehensive
geographical coverage. NHS England is developing a bespoke training programme
endorsed by the General Medical Council and Health Education England to address
this shortfall in practitioners. This is due for roll out imminently. There are currently
22 providers of thrombectomy services across the country, with 6 planning to
provide 24/7 access to thrombectomy and a further total of 13 who plan to provide a
7 day a week service. Regional NHS England teams are working with their service
providers to develop innovative solutions that include the development of joint rotas
so that patients have 24/7 access to thrombectomy within a region. As the
additional trained workforce becomes available the number of centres and the
number of centres able to provide 24/7 care will increase.
NHS England and NHS Improvement
Thrombectomy significantly reduces rates and levels of disability from stroke. It is
estimated that up to 10% of people who suffer a stroke will be medically eligible for
thrombectomy following a stroke which equates to approximately 8,000 patients per
year nationally. The target in the NHS Long Term Plan is that all eligible patients
will have access to thrombectomy by April 2022.
Thank you for bringing this important patient safety issue to my attention and please
do not hesitate to contact me should you need any further information.
Yours sincerely,
National Medical Director
NHS England and NHS Improvement
NHS England and NHS Improvement
Wellington House
133 – 155 Waterloo Road
London SE1 8UG
www.gov.uk/phe
Regulatory Services
London Borough of Camden
Camley Street
London N1C 4PP
24 April 2020
Dear Assistant Coroner R Brittain,
Re: Regulation 28: report to prevent future deaths
Thank you for your Regulation 28: report regarding
that could be taken to prevent future deaths.
and the actions
As you correctly point out in your report there is a causal link between cocaine use and
stroke. The risk can be heightened further by health and lifestyle factors such as diabetes,
hypertension or current smoking1.
While acute health problems associated with cocaine use are rare in most users, there are
many potential medical and psychiatric complications associated with its use. These
complications can be life threatening and include:
• cardiac problems, such as heart attacks
• pulmonary problems
• psychiatric illness, including anxiety, depression and psychosis
• neurological problems, including seizures and stroke
• gastrointestinal issues, and many others2
Cocaine use is the second most commonly used illicit drug in England. There are many
sources of information about cocaine and other illicit drugs, but it is possible that the risks
are misunderstood, minimised or ignored for various reasons by the public.
1 Cheng, Y. C., et al. (2016). Cocaine Use and Risk of Ischemic Stroke in Young Adults. Stroke, 47(4), 918–922.
2 Treadwell, S. D., & Robinson, T. G. (2007). Cocaine use and stroke. Postgraduate medical journal, 83(980), 389–394.
1
Information about the risks associated with cocaine use is widely available online from a
range of sources. This includes the NHS Live Well website and the FRANK website, which is
managed by Public Health England (PHE).
The FRANK website provides public advice and information on drugs, the risks and where to
get help. In response to your request, PHE will ensure that stroke is included in the health
risks of cocaine use on FRANK.
PHE is very aware of the prevalence of drug-related deaths in England. In 2018, there were
2,917 deaths related to drug misuse registered in England and Wales. In most cases,
opiates were mentioned on the death certificate.
In the same year, there were 637 deaths related to cocaine, almost double the number three
years earlier. However, it is not possible to distinguish between powder cocaine or crack
cocaine in these reported deaths3.
Most deaths where cocaine is mentioned on the death certificate are likely to be opioid
overdoses among people who used both heroin and crack cocaine.
The government has commissioned PHE to contribute to the second phase of the
independent review of drugs by Professor
review, which was published in February this year, recognised the increase in cocaine-
related deaths.
. Phase one of
Phase two will focus on treatment and prevention and will contain clear, evidence-based
recommendations to inform policy on drug misuse treatment and prevention. It will also look
at the availability and effectiveness of accurate information, education and other prevention
activities about drugs, including cocaine.
Yours sincerely
Deputy Director – Alcohol, Drugs, Tobacco and Justice
3 Deaths related to drug poisoning in England and Wales: 2018 registrations.
https://www.ons.gov.uk/peoplepopulationandcommunity/birthsdeathsandmarriages/deaths/bulletins/deathsrelatedtodrugpois
oninginenglandandwales/2018registrations.
2
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