Prevention of Future Deaths reports · 2020
Regulation 28 report to prevent future deaths, reference 2020-0123, written 28 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 | 28 Feb 2020 |
|---|---|
| Reference | 2020-0123 |
| Deceased | Peter Cole |
| Coroner | Geoffrey Sullivan |
| Coroner area | Hertfordshire |
| Category | Alcohol, drug and medication related deaths · Other 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.
Signed by Geoffrey Sullivan Title Senior Coroner Jurisdiction Hertfordshire _ REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: Sir Simon Stevens - Chief Executive NHS England 1 CORONER | am Geoffrey Sullivan Sentor Coroner for Hertfordshire 2 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. http://www. legislation.gov.uk/ukpga/2009/25/schedule/5/paragraph, http://www. legislation.gov.uk/uksi/2013/1629/part/7/made 3 INVESTIGATION and INQUEST On 19/09/2019 | commenced an investigation into the death of Peter COLE. Following a post mortem and toxicology analysis the cause of death provided was: 1a) Drug Overdose it} Ischaemic Heart Disease The investigation concluded at the end of the inquest 27th February 2020. The circumstances of the death recorded: On 14 August 2019 Peter Cole was found collapsed at his home address by a neighbour. He was unresponsive and CPR was started which was continued by ambulance crew and a return of output was achleved. Peter was transported to Lister Hospital where a CT chest showed bilateral lower lobe collapse/consolidation and multiple rib fractures from CPR. Following discussion with family, doctors decided no further resuscitation would be given and Peter died later that day. The conclusion of the inquest was: Prescription Drug Related 4 CIRCUMSTANCES OF THE DEATH Mr Cole was an older person with a diagnosis of dementia. He was in receipt of numerous prescription drugs, on repeat prescription. One of the drugs he was recelving was Tramadol, on a repeat prescription of 100 capsules per month over an extended period. The drug upon which he overdosed was Tramadol. | did not find 2 probable contribution to Mr Coles death as a result of the large quantity of repeat prescription drugs but heard that he had amassed a large quantity of prescription medication that he was simply not taking and was building up In his house. As a result of concerns raised about the extent of the drugs prescribed to him, | heard evidence from an experienced Mental Health Nurse. She outlined in her evidence that Mr Coles’ case was far from unusual. That she frequently visited patients who had amassed vast quantitles of unused medication and medical supplies. Often these patients were older and with varying degrees of mental Impairment. These drugs were Invariably on repeat prescription and the continued need for the drugs and/or compliance with the prescribed regime was not adequately supervised. One patlent had a ‘cupboard full’ of unused medication. = 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) That repeat medication is not being adequately monitored, leading to many (often older and/or mentally infirm) patients bullding-up dangerous quantitles of prescribed medication. (2) That the inadequate supervision of prescribed (repeat) medication is so widespread that the consequent waste of resources has an adverse Impact on the overall provision of healthcare. (3) | ACTION SHOULD BE TAKEN tn my opinion action should be taken to prevent future deaths and | believe you Sir Simon Stevens, Chief Executive NHS England, 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, namely by 27 April 2020. |, 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 | have sent a copy of my report to the Chief Coroner | am also under a duty to send the Chief Coroner a copy of your response. The Chief Coroner may publish elther or both ina 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 Chlef Coroner. 28/02/2020 —_p> Signature_ = Geoffrey Sullivan Sehior Coroner Hertfordshire
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.
Geoffrey Sullivan, Senior Coroner
Hertfordshire Coroner Service
The Old Courthouse
St Albans Road East
Hatfield
Hertfordshire
AL10 0ES
Professor Stephen Powis
National Medical Director
Skipton House
80 London Road
SE1 6LH
30th June 2020
Dear Mr Sullivan,
Re: Regulation 28 Report to Prevent Future Deaths – Peter Cole 14 August
2019
Thank you for your Regulation 28 Report dated 28 February 2020 concerning the
death of Peter Cole on 14 August 2019. Firstly, I would like to express my deep
condolences to the Cole family.
The regulation 28 Report concludes Peter Cole’s death was a result of drug
overdose and Ischemic Heart Disease.
Following the inquest, you raised concerns in your Regulation 28 Report to NHS
England and Improvement regarding:
•
•
repeat prescriptions not being adequately monitored, leading to many
patients building up dangerous quantities of prescribed medication; and
that as a result the inadequate supervision of repeat prescriptions is so
widespread that the consequent waste of resources has an adverse impact
on the overall provision of healthcare.
Thank you for raising these important points. Patient safety is the key responsibility
of all who work for the NHS and is at the heart of NHS system and process, with
NICE, the Care Quality Commission and the professional regulators and others,
providing supporting mechanisms. Delivering patient safety is complex as it relates
to all patient interactions and so ensuring effective delivery is on-going with learning
from experience and research informing progress.
Regarding the monitoring of repeat prescribing this is covered in the implementation
of the Long Term Plan1 which identifies better use of NHS resources as a priority
area. Work is ongoing to reduce the use of ineffective medicines as well as other
programmes relevant to medicines waste which NHS England and Improvement
1 https://www.longtermplan.nhs.uk/
NHS England and NHS Improvement
has responsibility for. Several workstreams are currently in place to optimise
prescribing and reduce medicines waste, these include:
• Carrying out Structured Medication Reviews: As part of the five year GP
contract Primary Care Networks (PCNS) are able to recruit additional staff to
work in primary care teams, this includes including clinical pharmacists.
Clinical pharmacists are increasingly working as part of general practice
teams. They are highly qualified experts in medicines and can help people in
a range of ways. This includes carrying out structured medication reviews for
patients with ongoing health problems and improving patient safety,
outcomes and value through a person-centred approach. They will support
GP practices in prioritising patients who would benefit from a structured
medication review. This will include patients in care homes; with complex
and problematic polypharmacy; on medicines commonly associated with
medication errors: and, with severe frailty, who are particularly isolated or
housebound. They will also work with community pharmacies to connect
patients appropriately to the New Medicines Service which supports
adherence to newly prescribed medicines.
• Supporting medicines optimisation through the Medicines Value Programme2
to improve health outcomes from medicines through supporting people to
take medicines as intended and, decreasing or stopping the use of
medicines which are neither clinically - or cost-effective;
• Undertaking a review of over-prescribing in the NHS which is due to report in
Spring 2020. The review covers: the role of digital technologies; research;
culture change and social prescribing; repeat prescribing; and transfer of
care. The report will provide recommendations to reduce overprescribing
which will help to reduce medicines wastage;
• Encouraging Shared Decision Making where a clinician supports a patient to
reach a decision about their treatment by a conversation that brings together
the clinician’s expertise: such as treatment options, evidence, risks and
benefits; with what the patient knows best: their preferences, personal
circumstances, goals, values and beliefs.
•
• The Medicines Safety Improvement Programme (MSIP) aims to reduce
medication related harm in the NHS, focusing on high risk drugs, situations
and vulnerable patients. The programme will contribute to the WHO
Challenge target to reduce severe avoidable medication-related harm
globally by 50% over five years.
In addition, to support improvement in dementia diagnosis and personalised care
for people with dementia, NHS England published The Dementia Care Pathway:
Full Implementation guidance . This resource sets out recommendations for
reviewing and managing medication needs and provides examples of step-by-step
best practice that includes monitoring and reviewing medication in the Appendices
and Helpful Resources section of the guide.
NHS England and Improvement also recently refreshed the Dementia: Good
Personalised Care and Support Planning guide to help further enhance the
provision of personalised post diagnostic support. The guide emphasises the need
to include medication reviews to help to reduce poly pharmacy, minimise use of
2 https://www.england.nhs.uk/medicines/medicinesoptimisation/
NHS England and NHS Improvement
drugs which impair cognition, to ensure that appropriate post diagnostic medication/
services are highlighted and accessed or stopped, as appropriate, at the right time
to improve outcomes for patients.
Thank you for bringing these important patient safety issues to my attention. I hope
the extensive work I have outlined reassures you that we are actively addressing
the points you raise. Please do not hesitate to contact me should you need any
further information.
Yours sincerely,
Professor Stephen Powis
National Medical Director
NHS England and NHS Improvement
NHS England and NHS Improvement
See every Prevention of Future Deaths report matching Alcohol, drug and medication related deaths, and how often a new one appears.
What would an alert for this have sent me? Search the full text
Free to try — the preview shows the real matches and how many arrived in the last 12 months. Your first email alert is free.
These reports are published by the Chief Coroner's office at judiciary.uk and are © Crown copyright. The text here is reproduced from the published PDF so it can be searched. If something on this page is wrong, or you are a person named in it and want it reviewed, email drcjar@gmail.com and we will act promptly.