Prevention of Future Deaths reports · 2020
Regulation 28 report to prevent future deaths, reference 2020-0258, written 26 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 | 26 Nov 2020 |
|---|---|
| Reference | 2020-0258 |
| Deceased | Neville Bardoliwalla |
| Coroner | Andrew Walker |
| Coroner area | London (North) |
| Category | Suicide (from 2015) · Other 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: Prevention of Future Deaths report
Neville Bardoliwalla (died 10/03/20)
THIS REPORT IS BEING SENT TO:
Department of Health and Social Care
39 Victoria Street,
Westminster
London SW1H OEU
1
CORONER
I am: H.M. Coroner and Senior Coroner Mr Andrew Walker
Senior Coroner for North
London
Barnet Coroner’s Court
29 Wood Street,
London EN5 4BE
2
CORONER’S LEGAL POWERS
I make this report under the Coroners and Justice Act 2009,
paragraph 7, Schedule 5, and
The Coroners (Investigations) Regulations 2013,
regulations 28 and 29.
3
INVESTIGATION and INQUEST
On 13th March 2020 I commenced an investigation into the death of Neville
Bardoliwalla. The investigation concluded at the end of the inquest held on
the 9th October 2020.
The conclusion of the inquest was a short form conclusion;
Suicide.
4
CIRCUMSTANCES OF THE DEATH
On the 10th March 2020 Mr Bardoliwalla was found having hanged
himself from two screws screwed into the top panel of the door frame at
his home.
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. Evidence was heard regarding the fact that prescribed controlled
medication had been accumulated by Mr Bardoliwalla and that there was
no process for of collecting and disposing of this medication.
6 ACTION SHOULD BE TAKEN
In my opinion, action should be taken to prevent future deaths and I believe
that 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 20th 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 following.
● The Bardoliwalla 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
26th November 2020. H M Coroner and Senior Coroner
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 D ep artm ent Parliamentary Under Secretary of State for Innovation of Health & 39 Victoria Street Lond Social Care SWiHOEU 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 26 November 2020 about the death of Neville Bardoliwalla. lam replying as Minister with responsibility for medicines. Firstly, | would like to say how sorry | was to read the circumstances of Mr Baroliwalla’s death and | offer my most heartfelt condolences to Mr Bardoliwalla’s family and loved ones at what must be a distressing time. | note that this is the second Prevention of Future Deaths report you have issued to the Department of Health and Social Care about the disposal of controlled drugs. | wish to assure you that we recognise the importance of having 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 tmprovement, 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 managemeni?, published by the National Institute for Health and Care Excellence (NICE) in 2016. 2 httos:/Awww.nice.org.uk/quidance/ng46 [1.5.11] | should also explain that work is underway to reduce waste medicines in the first place. 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 rare 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 concerns to my attention. LORD BETHELL 3 https://www.england.nhs.uk/medicines-2/value-programme/
See every Prevention of Future Deaths report matching Suicide (from 2015), 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.