Prevention of Future Deaths reports · 2020
Regulation 28 report to prevent future deaths, reference 2020-0077, written 24 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 | 24 Mar 2020 |
|---|---|
| Reference | 2020-0077 |
| Deceased | Simon Delahunty |
| Coroner | Andrew Walker |
| Coroner area | London (North) |
| Category | Suicide (from 2015) · Alcohol, drug and medication related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
Her Majesty’s Coroner for the Northern District of Greater London (Harrow, Brent, Barnet, Haringey and Enfield) North London Coroners Court, 29 Wood Street, Barnet EN5 4BE Telephone 0208 447 7680 0208 447 7689 Fax REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: Ministerial Correspondence and Public Enquiries Unit Department of Health and Social Care 39 Victoria Street London SW1H 0EU 1 CORONER I am Andrew Walker, senior coroner, for the coroner area of Northern District of Greater London 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 the 21st day of October 2019 I opened an investigation touching the death of Simon Anthony Delahunty aged 46 years old. I opened an inquest on the 29th October 2019. The inquest concluded on the 30th January 2020. The conclusion of the inquest was “Suicide contributed to by the circumstances within his life". The medical cause of death was 1a Hypoxic Brain Injury, 1(b) Hypoxic Cardiac Arrest and 1(c) Overdose of Oramorph ,Midazolam, Paracetamol beer and Vodka.. CIRCUMSTANCES OF THE DEATH On the Second of October 2019 Simon Anthony Delahunty took an overdose of medication prescribed for another patient who had recently died at the address. The medications were part of end of life care that had been left at the the address . It is likely that Mr Delahunty's actions were impulsive as he had made arrangements to stay for some time at this address. 4 5 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. – There are no arrangements or guidance concerning the collection or disposal of unused end of life prescription medication. Her Majesty’s Coroner for the Northern District of Greater London (Harrow, Brent, Barnet, Haringey and Enfield) 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you [AND/OR your organization] 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 the 19th May 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. 8 COPIES and PUBLICATION I have sent a copy of my report to the Chief Coroner and to the following Interested Persons;- The Family. I 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 24-3-2020
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.
a From the Lord Bethelf Department Parliamentary Under Secretary of State for innovation of Health & 39 Victoria Street Lond Social Care Storer Our Ref 020 7210 4850 Mr Andrew Walker HM Senior Coroner, North London HM Coroners Court 29 Wood Street Barnet EN5 4BE 15 December 2020 Dear Andrew, Thank you for your letter of 24 March 2020 about the death of Simon Anthony Delahunty. | am replying as Minister with responsibility for medicines and as your letter only came to the Department's attention on 7 October 2020, | am grateful for the additional time in which to make this response. Firstly, | would like to say how sorry | was to read the circumstances of Mr Delahunty's death and | offer my sincere condolences to Mr Delahunty’s family and loved ones. We agree that it is important to have methods to dispose of medicines waste safely, that protect the public from harm. Disposal of unwanted medicines is an essential service of the NHS Community Pharmacy Contractual Framework’, to be provided by all community pharmacies in England. This requires them to accept unwanted medicines from private households, residential care homes and children's homes. These returned medicines are then stored securely and safely by pharmacies until they are collected for safe disposal. NHS England and NHS Improvement, as commissioners of NHS Pharmaceutical Services, have arrangements in place for a waste contractor to collect the unwanted medicines from pharmacies at regular intervals for safe disposal. This ensures that the public have an easy method of returning unwanted medicines to pharmacies for safe disposal, helping to reduce harm to themselves and environmental damage caused by inappropriate disposal methods. Patients or their families and carers, should be advised by community nursing staff, GPs or pharmacists to return any unwanted or unrequired medicines to their local community pharmacy for safe disposal. This recommendation is made in National Guideline 46 Controlled Drugs: safe use and management?, published by the National Institute for Health and Care Excellence (NICE) in 2016. " https /Awww.gov.uk/government/publications/community-pharmacy-contractual-framework-2019-to-2024 ? https:/Awvww.nice.org.uk/quidance/ng4é [1.5.11] Following a patient's death, any unused medicines should also be returned to a community pharmacy for safe disposal. Possession of a controlled drug by someone other than the person for whom it was dispensed is illegal. This does not prevent the transport of controlled drugs to patients, or the returning of drugs to pharmacies for safe disposal. NICE National Guideline 46: Controlled drugs: Safe use and management, contains additional guidance on following locally agreed processes for reviewing anticipatory prescribing of controlled drugs. These local processes include assessing the risk to others in the patient's household or with access to their home if controlled drugs are to be supplied and prescribed in anticipation of need at the end of life. The risk and likelihood of accidental or deliberate overdose, misuse and diversion are all matters that should be considered. Additionally, in circumstances where a local risk assessment has identified that the continued presence of the controlled drugs poses a significant and immediate risk, either of deliberate or accidental harm, then local arrangements may be made to remove the controlled drugs from the home for destruction. 1 hope this information is helpful. It may also interest you to note that work is underway to reduce waste medicines in the first place, which may help mitigate situations highlighted by the unfortunate circumstances surrounding Mr Delahunty's death. Medicines optimisation is a key workstream within NHS England's Medicines Value Programme? that aims to ensure that the right patients get the right choice of medicine, at the right time. Through focusing on patients and their experiences, the goal is to help patients to improve their outcomes; take their medicines as intended; avoid taking unnecessary medicines; reduce wastage of medicines; and improve medicines safety. In addition, the Secretary of State for Health and Social Care, Matt Hancock, has asked Dr HE, the Chief Pharmaceutical Officer for England, to carry out a review of over- prescribing in the NHS. This work is looking at reducing inappropriate prescribing, with a particular focus on the role of digital technologies; research; culture change and social prescribing; repeat prescribing; and transfer of care. The report of the review will provide recommendations to reduce overprescribing to improve patient safety and reduce medicines wastage. | hope this response is helpful. | am grateful to you for bringing these concerms to my attention. LORD BETHELL 3 https:/Avww.england.nhs.uk/medicines-2/value-programme/
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