Prevention of Future Deaths reports · 2020
Regulation 28 report to prevent future deaths, reference 2020-0253, written 23 Nov 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 Nov 2020 |
|---|---|
| Reference | 2020-0253 |
| Deceased | Claire Richards |
| Coroner | Crispin Oliver |
| Coroner area | County Durham and Darlington |
| Category | Mental Health related deaths · 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.
REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: Secretariat of the Advisory Council on the Misuse of Drugs C/O The Home Office Acmd@homeoffice.gov.uk 1 CORONER I am Crispin A Oliver, Assistant Coroner, for the coroner area of County Durham and Darlington. 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 19th March 2020 I commenced an investigation into the death of Claire Richards, 39 years old. The investigation concluded at the end of the inquest on 20th November 2020. The conclusion of the inquest was that Claire Richards died from 1a) Toxic Effects of Pregabalin and Buprenorphine and the conclusion was that it was a Drug Related Death. 4 CIRCUMSTANCES OF THE DEATH Claire Richards had a history of drugs misuse and mental health issues. She was pronounced dead at home. She had been snorting illegally dealt pregabalin and buprenorphine in the days before her death. She became very unwell, then unresponsive. Eventually those she was with summoned the emergency services, but she could not be saved and died at home. She did not intend her own death. 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. This is notwithstanding that the concern is one concerning something which is endemic, and this case simply provides a paradigm example. I have previously sent a report in this case to the Chief Executive of the Royal Pharmaceutical Society who has replied suggesting that I send it to you. It is my statutory duty to report to you. The MATTER OF CONCERN is as follows. – (1) This case involves a death resulting from illegally dealt prescription drugs. It is of increasing concern that prescription drugs are available in vast quantities for illegal dealing to vulnerable people. (2) What steps are projected, or are actually in the pipe line, for stemming the leakage of prescription medication out of the lawful dispensing process into criminal hands? 6 ACTION SHOULD BE TAKEN In my opinion, action should be taken to prevent future deaths and I believe you and your organisation 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 29th April 2021. 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 Next of Kin of , who is an Interested person in the Inquest. 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 Dated: 26th February 2021 Signed: CRISPIN A OLIVER HM SENIOR ASSISTANT CORONER COUNTY DURHAM AND DARLINGTON
Regulation 28: REPORT TO PREVENT FUTURE DEATHS REGULATION 28 REPORT TO PREVENT DEATHS THIS REPORT IS BEING SENT TO: Paul Bennett, Chief Executive Officer The Royal Pharmaceutical Society 66 East Smtihfield London E1W 1AW 1 CORONER I am Crispin OLIVER, Assistant Coroner for the area of County Durham and Darlington 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 Nineteenth March 2020 I commenced an investigation into the death of Claire RICHARDS aged 34. The investigation concluded at the end of the inquest on Twentieth November 2020. The conclusion of the inquest was Drug related: I a Toxic Effects of Pregabalin and Buprenorphine I b I c II 4 CIRCUMSTANCES OF THE DEATH Claire Richards had a history of drugs misuse and mental health issues. She was pronounced dead at home. She had been snorting illegally dealt pregabalin and buprenorphine in the days before her death. She became very unwell, then unresponsive. Eventually those she was with summoned the emergency services, but she could not be saved and died at home. She did not intend her own death. 5 CORONER’S CONCERNS The MATTERS OF CONCERN are as follows: 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. This is notwithstanding that the concern is one concerning something which is endemic, and this case simply provides a paradigm example. It is my statutory duty to report to you. The MATTER OF CONCERN is as follows. – (1) This case involves a death resulting from illegally dealt prescription drugs. It is of increasing concern that prescription drugs are available in vast quantities for illegal dealing to vulnerable people. (2) What steps are projected, or are actually in the pipe line, for stemming the leakage of prescription medication out of the lawful dispensing process into criminal hands? 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you (and/or your organisation) 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 18 January 2021.However, given the time of year and the current national health emergency I propose to extend that to 26th of January 2021. 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 , …………………………………………………………………………………………………………………… 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 Crispin OLIVER Assistant Coroner for County Durham and Darlington Dated: 23 November 2020 NOTE: This from is to be used after an inquest.
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.
Crispin Oliver HM Assistant Coroner for County Durham and Darlington PO Box 282 Bishop Auckland Co Durham DL14 4FY 12 February 2021 Dear Mr Oliver, Re: Regulation 28 Prevention of Future Deaths report for Clare Richards, deceased Thank you for your letter dated the 8th February 2021 and for sending the report of the inquest into the death of Claire Richards dated 23rd November 2020. We would like to express our sincere condolences to Claire’s family. We do not have a record of receiving the report in November 2020. If there was a communication at the time, can you let us know who and where this was addressed to together with the communication type and we can investigate further. The Royal Pharmaceutical Society (‘RPS’) is the professional body for pharmacists and pharmacy in Great Britain, representing all sectors of pharmacy. Our role is to lead and support the development of the pharmacy profession including the advancement of science, practice, education and knowledge in pharmacy. We transferred our regulatory role to the General Pharmaceutical Council (‘GPhC’) in 2010, and they now regulate pharmacy and pharmacy professionals in Great Britain. We note and share your concerns regarding the misuse of prescription medicines including pregabalin and gabapentin. As the professional body we work with the profession to promote best practice in the safe and effective supply of medicines and pharmaceutical care for people receiving medicines from pharmacy. The report outlined matters of concern including the availability of prescription medicines to vulnerable people illegally, or outside of the healthcare system and controls on availability. For this reason we believe it would be appropriate for Public Health England (PHE) and the Advisory Council for the Misuse of Drugs (ACMD), who both have roles around the misuse of drugs to be aware of this report. The misuse of prescription drugs is monitored by PHE and in their latest quarterly report published December 2020 noted that registered deaths involving pregabalin have increased from 136 in 2017 to 244 in 20191. PHE is an executive agency of the Department of Health with a role to protect and improve health and wellbeing and reduce inequalities. https://www.gov.uk/government/organisations/public-health-england The role of the ACMD is to make recommendations to Government on the control of dangerous and harmful drugs. https://www.gov.uk/government/organisations/advisory-council-on-the- misuse-of-drugs It was following concerns raised by the ACMD that pregabalin was added to the Misuse of Drugs Regulations in 2019. Thank you for bringing this to our attention. If there is more information you would like to share please do not hesitate to contact us again. I hope our response has been helpful Yours sincerely Chief Executive Royal Pharmaceutical Society 1 Public Health England. Quarterly summary for professionals – December 2020. https://khub.net/web/phe-national/public-library/- /document_library/v2WsRK3ZlEig/view_file/395143611?_com_liferay_document_library_web_portle t_DLPortlet_INSTANCE_v2WsRK3ZlEig_redirect=https%3A%2F%2Fkhub.net%3A443%2Fweb%2F phe-national%2Fpublic-library%2F- %2Fdocument_library%2Fv2WsRK3ZlEig%2Fview%2F345595238
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