Prevention of Future Deaths reports · 2020
Regulation 28 report to prevent future deaths, reference 2020-0186, written 28 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 | 28 Sep 2020 |
|---|---|
| Reference | 2020-0186 |
| Deceased | June Parlour |
| Coroner | Lincoln Brookes |
| Coroner area | Essex |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| Organisation named | East Suffolk and North Essex NHS Foundation Trust |
| 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. East Suffolk and North Essex NHS Foundation Trust 1 CORONER I am Lincoln Brookes, Area Coroner for Essex. 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 16/08/2019 I commenced an investigation into the death of June Patricia Margaret PARLOUR (then aged 74). The investigation concluded at the end of the inquest on 22/09/2020. The conclusion of the inquest was: Medical Cause of Death: I a Opiate Toxicity b c II Disseminated carcinoma of unknown primary. Narrative Conclusion: On 11 May 2019 at Colchester General Hospital, Turner Road, Colchester, Essex, June Patricia Margaret PARLOUR died of opiate toxicity following administration of morphine doses that cumulatively amounted to an inadvertent and fatal overdose. She had been an inpatient, suffering from disseminated terminal cancer, and the overdose hastened her death significantly. The overdose occurred as a result of a breakdown in communication between staff and was contrary to both hospital and national guidelines. 4 CIRCUMSTANCES OF THE DEATH Mrs June Parlour was an inpatient at Colchester General Hospital, Turner Road, Colchester, Essex, suffering from, amongst other matters, disseminated terminal cancer which had spread to her liver but had yet to be considered for a palliative pathway. At around 12.30am on 11/5/2018 she was prescribed and given 10mg of Oramorph (oral liquid morphine) for abdominal pain and was given a further 10mg dose of morphine intravenously. Both of these doses where in excess of national BNF guidelines and indeed those of the hospital (and in terms of the IV dose being untitrated). Mrs Parlour was particularly vulnerable to the effects of morphine by reason of her advanced age, her opiate naivety and her compromised liver. Mrs Parlour’s condition deteriorated and she was given Naloxone to reverse the over-sedation. She was then placed on a palliative pathway, administered a further 2mg of morphine and died later that morning of opiate toxicity. It was the finding of the Court that the overdoses had significantly hastened her death. 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 could 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) During the course of the hearing it became apparent that staff on the ward (whether doctor or nurse) were not familiar with either the national morphine guidelines (BNF) or indeed those of the hospital. The Court is concerned that such lack of awareness may not be limited to that ward or that hospital. (2) It was concerning that even the hospital’s own Serious Incident report had incorrectly quoted the hospital’s guidelines as to the safe dose of IV morphine and that neither the investigatory team or any of the clinical staff who subsequently read that report had picked up on this. (3) I am concerned as to the adequacy of education re safe morphine doses that newly qualified doctors and locum doctors receive, and how this is audited. 4) I am concerned that the hospital’s own guidelines regarding morphine administration for acute pain management have not been revised since 2013 and are at odds with the current BNF guidelines (in terms of appropriate doses and patient vulnerability). 5) I was concerned that this incident arose as a result of a doctor and a nurse failing to understanding each other, and the nurse subsequently feeling that she had no choice but to administer an IV dose that she believed to be dangerous, and in particular that: a) The drug charts design did not facilitate clear instructions for titration for one-off doses of IV morphine. b) The nurse did not feel confident enough to challenge the prescription (as she perceived it) effectively or escalate / refer to another doctor. 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe your organisation has 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 4pm 24/11/2020. 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: (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 28/9/2020 LINCOLN BROOKES – AREA CORONER FOR ESSEX
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.
Mr Lincoln Brookes Coroner for Essex A Block Chelmsford County Hall Victoria Rd S Chelmsford CM11QH t4'7#bj East Suffolk and North Essex NHS Foundation Trust Trust Headquarters Colchester Hospital Turner Road Mile End Colchester Essex C04 5JL Date: 23 November 2020 Dear Mr Brookes, Re: June Patricia Margaret Parlour (Deceased) I am writing in response to the Regulation 28 Report to prevent future deaths issued following the inquest of June Patricia Margaret Parlour. ESNEFT is committed to learning lessons and taking action to ensure the future safety of patients in our care. We have taken following actions in response to the following concerns detailed within your report: 1. During the course of the hearing it became apparent that staff on the ward (whether doctor or nurse) were not familiar with either the national morphine guidelines (BNF) or indeed those of the hospital. The Court is concerned that such lack of awareness may not be limited to that ward or that hospital. We have reviewed and updated the ESNEFT Morphine Administration Guideline and the Naloxone Administration Guideline in line with those set out in the British National Formulary (BNF). Both guidelines have been communicated to staff through the Chief Medical Officers 'Doctors Round' and the Chief Nurse Brief. Further to this, the guidelines are published on the Trust intranet and on the medications specific application 'Medusa' where they are easily accessible by staff in all areas within the Trust. To capture Doctors in training , the Medical Directors of Education have engaged and communicated the guidelines, and updated the junior doctor induction programme to ensure this is embedded in practice moving forward . The use of Morphine and Naloxone are monitored through the Controlled Drugs Steering Group through review of all incidents reported. There is a current programme of Opioid auditing which takes place across the Trust. 2. It was concerning that even the hospital's own Serious Incident report had incorrectly quoted the hospital's guidelines as to the safe dose of IV morphine and that neither the investigatory team or any of the clinical staff who subsequently read that report had picked up on this. We are disappointed that this was not picked up within our serious incident approval process and will ensure closer attention in the future. The Trust has been selected as one of the early adopters for the new NHS Patient Safety Incident Response Framework, which commenced on the 2 November 2020. In establishing the new framework ESNEFT has put in place a number of highly trained investigating officers to lead the patient safety incident investigations, utilising relevant clinical experts within the process. Through a team approach to investigations, greater scrutiny of the information and evidence provided will be undertaken and will support a timely response to incidents and the identification of improvements required. The framework aims to ensure investigations are undertaken in a timely manner and with a greater involvement of patients, families and carers. 3 . I am concerned as to the adequacy of education re safe morphine doses that newly qualified doctors and locum doctors receive, and how this is audited. As mentioned above we have updated the junior doctor induction programme, incorporating an additional module specific to prescribing high risk medications (such as Morphine) and introduced additional training for our higher grade doctors in training . We have updated our locum and agency staff induction, with includes signposting to the relevant documents on the intranet and on the Medusa system. All locum and agency staff, in conjunction with the local ward team complete an induction form which is subsequently sent to the Education Team who monitor adherence with the induction process. 4. I am concerned that the hospital's own guidelines regarding morphine administration for acute pain management have not been revised since 2013 and are at odds with the current BNF guidelines (in terms of appropriate doses and patient vulnerability). We have reviewed and updated the ESNEFT Morphine Administration Guideline and the Naloxone Administration Guideline in line with those set out in the British National Formulary (BNF). We have also updated the ESNEFT Acute Pain Guideline, which is scheduled for approval by the Medications Governance Group at its meeting on 03rd December 2020. This guideline will be subject to audit by the Acute Pain Team . This meeting is held bi-weekly in response to the pandemic. Further to this, all opioid related medication guidelines are within their review dates. 5. I was concerned that this incident arose as a result of a doctor and a nurse failing to understanding each other, and the nurse subsequently feeling that she had no choice but to administer an IV dose that she believed to be dangerous, and in particular that: a) The drug charts design did not facilitate clear instructions for titration for one-off doses of IV morphine. Through a QI process we have developed and approved a new Morphine Prescription sticker for use on prescription charts across all inpatient areas. These are currently out to printers, with a planned roll out programme to take place in December 2020. To close the loop on the QI process this will be subject to audit by the Acute Pain Team. Further to this we have updated the Morphine Administration Competency. Framework for inpatient staff who administer and monitor morphine administration. b) The nurse did not feel confident enough to challenge the prescription (as she perceived it) effectively or escalate I refer to another doctor. We anticipate that the introduction of the Morphine Prescription sticker will provide clarity of prescription and support raising a concern when required . ESNEFT encourages all staff to speak up and has a positive reporting culture with regards to patient safety. Work is on-going in accordance with the 'Just Culture Guide', through the Patient Safety Incident Response Framework and through the NHS Programme of Patient Safety Specialists across the NHS. All nursing staff have been reminded that there is a Duty Matron available 24/7 and consultants on-call, to whom all staff can escalate any concerns or ask questions, in addition to the Consultants on-call Again I offer my assurance that ESNEFT is committed to learning lessons and taking action to ensure the future safety of patients in our care. Yours sincerely - Chief Executive
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