Prevention of Future Deaths reports · 2020
Regulation 28 report to prevent future deaths, reference 2020-0181, written 23 Sep 2020. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 23 Sep 2020 |
|---|---|
| Reference | 2020-0181 |
| Deceased | Christine Forbes |
| Coroner | Emma Serrano |
| Coroner area | Derby and Derbyshire |
| Category | Community health care |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
Text extracted from the PDF text layer. 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. Clinical Commissioning Groups (“CCG”); 2. NHS England; 3. Primary Care Support England; 4. Chief Coroner; and 5. Family of the deceased. 1 CORONER I am Emma Serrano, Assistant Coroner, for the coroner area of the Derby and Derbyshire. 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 10th February 2020, I commenced an investigation into the death of Mrs Christine Forbes. The investigation concluded at the end of the inquest on 22 September 2020. The conclusion of the inquest was a short form conclusion of suicide. The cause of death was: 1a Combined Oxycodone and Zolpidem Toxicity; and II Coronary Artery Atherosclerosis CIRCUMSTANCES OF THE DEATH 4 i) Mrs Forbes was a 72 year old woman who had a history of operation induced incontinence and pain management. She broke her leg in 2016 and this required treatment as well as pain management. She was prescribed oxycodone. In May 2017, having stockpiled her oxycodone, she took an international overdose. This was unsuccessful. ii) On the 29 September 2019 she again broke her leg. She was seen by a consultant at the Royal Derby Hospital. She was prescribed oxycodone. She was then prescribed oxycodone, by her usual GP surgery, the Bollington Practice, twice over the course of the following two months. iii) She registered with the Ashbourne Surgery in Derby on the 28 November 2019. This surgery had no information about Mrs Forbes. It is standard practice that, once a patient registers with a particular surgery, a request for their medical notes is made. This request is made to Primary Care Support England. It can take a significant amount of time for these to be sent. In 1 [IL1: PROTECT] relation to Mrs Forbes, her medical history and notes did not arrive with Ashbourne Surgery until shortly before Mrs Forbes passed away. iv) On the 11 December Mrs Forbes was prescribed oxycodone by Ashbourne Surgery’s Pharmacist. This was done without the pharmacist having access to relevant information regarding Mrs Forbes, namely, her previous stockpiling and misuse of oxycodone and any previous episodes of self- harm or suicide. v) On the 2 February 2020 Mrs Forbes took oxycodone and zolpidem in quantities that caused her to pass away. She left a suicide note and her last will and testament for her husband to find. This was the same manner in which she had tried to take her own life in May 2017. vi) It was accepted, at inquest that the prescription of the oxycodone to Mrs Forbes was completed on the 11 December 2019, by Ashbourne Surgery’s Pharmacist. This was done without the Pharmacist having access to the medical notes of Mrs Forbes. These would have contained her previous medical history and would have allowed for a more meaningful review before the decision to prescribe was made. vii) It was stated in evidence that it is usual for a new patient to register at a GP practice and, for the notes for that patient to follow a significant time after the registration. 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. – 1. That when patients register at GP surgeries (across England) they do so without their medical notes and history. This material can take a significant amount of time to be sent to a GP practice after a request is sent to Primary Care Support England. Doctors and other medical practitioners are therefore treating and prescribing in situations where a full medical history is not known. 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I 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 11 November 2020. 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: 2 [IL1: PROTECT] 1. Clinical Commissioning Groups (“CCG”); 2. NHS England; 3. Primary Care Support England; and 4. Family of the deceased. 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 23 September 2020 Miss Emma Serrano Assistant Coroner Derby and Derbyshire Coroners Area 3 [IL1: PROTECT]
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.
Scarsdale Nightingale Close Off Newbold Road Chesterfield S41 7PF Tel: www.derbyandderbyshireccg.nhs.uk Our Ref: 6th November 2020 Private & Confidential Miss Serrano Assistant Coroner Derby & Derbyshire Coroners Area St Katherine’s House St Mary’s Wharf, Mansfield Road Derby DE1 3TQ Dear Miss Serrano Re: Regulation 28 Report to Prevent Future Deaths – Mrs Christine Forbes Thank you for your Regulation 28 Report dated 23 September 2020 concerning the death of Mrs Christine Forbes on the 2 February 2020. Firstly, I would like to express my deep condolences to Mrs Forbes family. The regulation 28 report concludes Mrs Forbes death was a result of Combined Oxycodone and Zolpidem Toxicity; and Coronary Artery Atherosclerosis Following the inquest you raised concerns in your Regulation 28 to NHS Derby and Derbyshire Clinical Commissioning Group – That when patients register at GP surgeries (across England) they do so without their medical notes and history. This material can take a significant amount of time to be sent to a GP practice after a request is sent to Primary Care Support England. Doctors and other medical practitioners are therefore treating and prescribing in situations where a full medical history is not known. In response to the concerns raised: All general practices across Derby and Derbyshire are enabled for GP2GP electronic record transfer; this is an electronic system which allows patients' electronic health records to be transferred between their old and new practices within a matter of minutes (at most 24hrs) , when a patient registers with a new GP Practice. Head office address: 1st Floor North, Cardinal Square, 10 Nottingham Road, Derby, DE1 3QT Chief Executive Officer: Chair: The aim of GP2GP is to: • Improve patient care by making full and detailed medical records available to the patient’s new practice to support first and later consultations. • Prevents the need for a patient to provide their past medical history as this is already visible to the clinician seeing the patient. • Supports safer prescribing provided through access to the patient's current and past medication and to any recorded allergies and adverse reactions and repeat medication details will be available for the patient's first medication review with the new GP Where GP2GP electronic record fails this is usually due to the sending (previous practice) not being enabled, the record is too large (very rare) or the patient has transferred from outside of England. In these events the receiving practice should contact the sending practice and record through Primary Care request a full patient print-out whilst awaiting the Services England. In response to the Regulation 28 concern NHS Derby and Derbyshire Clinical Commissioning Group have liaised with Ashbourne Medical Practice to support a comprehensive reply. We shared the concern raised by the coroner and the practice has undertaken further investigation into the GP2GP electronic record transfer. In summary the practice actioned the GP2GP electronic record transfer on the date that Mrs Forbes registered at the practice on the 28.11.2019 SystmOne are not able to show what Mrs Forbes record may have looked like on a particular date, but they confirmed that when the GP2GP transfer task was actioned (on 28/11/2019) all previous electronic data including correspondence should have been integrated into the record. The practice process at the time of Mrs Forbes registration was that new patient records were summarised by administrative staff once the paper notes arrived, and as part of this process both the paper notes and the electronic record were reviewed. The paper notes were received at the practice on 14th January 2020 (7 weeks after registration - usual timeframe), however administrative staff did not summarise them in this case before Mrs Forbes death (which occurred within 3 weeks of receipt of the paper notes). The practice has put a new process in place where any electronic records dated in the last 3 months are reviewed by administrative staff for any urgent safeguarding events / suicide etc. This would prompt administrative staff to prioritise those records for summarising once arrived and alert the responsible GP. The practice also looked at the pharmacist’s consultation on 11/12/2019. The pharmacist linked the 'medication review done' code to 2x problems which were recorded in 2016 and 2017 - this would suggest that he was able to see information previously recorded. His consultation was recorded contemporaneously. Derby and Derbyshire CCG commission the North of England Commissioning Support Unit to support GP Primary Care Informatics; this includes modular training over a range of subjects including GP2GP Electronic Record Transfer and Note Summarisation. In response to the raised concern Derby and Derbyshire CCG will: Head office address: 1st Floor North, Cardinal Square, 10 Nottingham Road, Derby, DE1 3QT Chief Executive Officer: Chair: • Offer additional GP2GP/ Record Transfer training to Ashbourne Medical Practice • Offer additional training Note Summarisation to Ashbourne Medical Practice • Circulate information about available GP2GP and Note Summarisation training to all • • practices. Include information about GP2GP and Note Summarisation training into the GP Membership Bulletin Include overview of available training within DDCCG Clinical Governance leads meetings Thank you for bringing these important patient safety issue to my attention and please do not hesitate to contact me should you need any further information. Yours sincerely Executive Medical Director NHS Derby and Derbyshire Clinical Commissioning Group cc: , Associate Medical Director , Head of Corporate Development Head office address: 1st Floor North, Cardinal Square, 10 Nottingham Road, Derby, DE1 3QT Chief Executive Officer: Chair:
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