Prevention of Future Deaths reports · 2021
Regulation 28 report to prevent future deaths, reference 2021-0008, written 11 Jan 2021. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 11 Jan 2021 |
|---|---|
| Reference | 2021-0008 |
| Deceased | Natalie Edgington |
| Coroner | Catherine McKenna |
| Coroner area | Manchester North |
| Category | Community health care · 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.
REGULATION 28: REPORT TO PREVENT FUTURE DEATHS (1) | REGULATION 28 REPORT TO PREVENT FUTURE DEATHS | THIS REPORT IS BEING SENT TO: | 1. a ce Medical Director, Turning Point | CORONER | am Catherine McKenna, Area Coroner for the Coroner area of Manchester North 4 CORONER'S LEGAL POWERS | make this report under paragraph 7, Schedule 5, of the Coroner's and Justice Act 2009 and Regulations 28 and 29 of the Coroners (Investigations) Regulations 2013 INVESTIGATION and INQUEST On the 27 February 2020, | commenced an investigation into the death of Natalie Jane Edgington. The investigation concluded at the end of the inquest on 11 January 2021 when | returned a Narrative Conclusion, ‘The Deceased died as a result of a complication of prescribed medication.’ The medical cause of death was: ja) Methadone toxicity 1b) Fatty liver disease 2) Liver cirrhosis CIRCUMSTANCES OF DEATH Natalie Edgington was 28 years old when she died at her mother’s address on 24 February 2020. Ms Edgington had a history of chronic liver disease and had been discharged from Gastroenterology services in October 2019 due to her non-attendance at liver clinic appointments. The Deceased was on a repeat prescription for codeine phosphate for abdominal pain secondary to liver problems and the evidence was that consideration had previously been given to the prescription of spironolactone for ascites. On 8 January 2020, the Deceased self-referred to Turning Point in Rochdale for support with opiate dependency. She was assessed by a nurse prescriber who noted her chronic liver disease and wrote to her GP on 22 January 2020 requesting any recent blood tests. There is no evidence that the GP responded to this letter or that a liver function test was requested by Turning Point. On 29 January 2020, the Deceased was prescribed a titrating dose of methadone progressing from 30 mis to 60 mls over the course of 9 to 12 days. The Deceased’s mother contacted Turning Point on 11 February 2020 to inform them that the Deceased had been vomiting for 5 days and was too unwell to collect her methadone. Alternative arrangements were made for the collection of the prescriptions. The Deceased did not attend an appointment that was offered by the GP on 11 February or respond to a message left by her recovery worker on 20 February. The Deceased was found dead at her mother's address on 24 February 2020. She died of the effects of an accumulation of methadone which she had been unable to properly eliminate due to an impairment of her tiver function. 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 prescribers should have full information about the nature and extent of a service user’s liver disease in order to ensure that prescribing is within safe limits. The prescription to the Deceased was issued without relevant medical information that could have been obtained from the GP and/or an up to date liver function test. There is a risk associated with reliance on a service users self-reporting of his/her own medical history particularly against a background of non-attendance at medical appointments. 2. The BNF recommends that consideration should be given to starting patients with a history of liver disease on a lower dose of methadone than the standard starting dose of 30mls. There was no evidence to suggest that any consideration was given to starting the Deceased on a lower dose. 6 ACTION SHOULD BE TAKEN in my opinion action should be taken to prevent future deaths and | believe each of you respectively 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 9 March 2021. |, the Area 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 | have sent a copy of my report to the Chief Coroner and to the following Interested Persons namely:- ° nother of the Deceased) e Hopwood Medical Centre, 1-3 Walton Street, Heywood, OL10 2BS lam 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 from. 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 7] Date: \\ ny Yor Signed: ( WEE
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.
Turning Point
The Exchange
3 New York Street
Manchester
M14HN
www.turning-point.co.uk
TURNING
POINT
Inspired by possibility
Her Majesty's Area Coroner
Ms Catherine McKenna
The Phoenix Centre
L/Cpl Stephen Shaw MC Way
Heywood
Oll0 lLR
5th March 2021
Madam,
Natalie Jane Edgington
Your reference: 68821
Response to Regulation 28 Report to Prevent Future Deaths
I write in response to the Regulation 28 Report to Prevent Future Deaths (PFD) dated 11 January
2021 in which you highlighted two concerns which arose during the inquest into the death of Ms
Edgington.
In what follows I set out the actions that have been taken by Turning Point in relation to your
concerns. We were not an Interested Person in this inquest and therefore have not had full
disclosure of all evidence before the Court which led to your concerns. However, I hope that this
letter provides reassurance that Turning Point takes your concerns very seriously, has thoroughly
reviewed the issues raised and has taken appropriate measures to ensure the risk of any future death
connected with these issues is minimised as far as possible.
Concerns
That prescribers should have full information about the nature and extent of a service user's liver
disease in order to ensure that prescribing is within safe limits. The prescription to the Deceased was
issued without relevant medical information that could have been obtained from the GP and/or an up
to date liver function test. There is a risk associated with reliance on a service users self-reporting of
his/her own medical history particularly against a background of non-attendance at medical
appointments
The BNF recommends that consideration should be given to starting patients with a history of liver
disease on a lower dose of methadone than the standard starting dose of 30mls. There was no
evidence to suggest that any consideration was given to starting the Deceased on a lower dose.
TURNING POINT IS A REGISTERED CHARITY, NO. 234887, A REGISTERED SOCIAL LANDLORD AND A COMPANY LIMITED BY GUARANTEE NO. 793558 (ENGLAND & WALES
REGISTERED OFFICE: STANDON HOUSE, 21_MANSELL STREET, LONDON, El SAA.
t!J&I disability
ri1 G1 confident
COMMITTED
INVESTOR IX PEOPLE
CHIEF EXECUTIVE:
TURNING
POINT
inspired by possibility
Response
Turning Point
The Exchange
3 New York Street
Manchester
M14HN
www.turning-point.co.uk
Please find below the actions that we have taken within the organisation in relation to your
concerns.
1) We have produced an educational support pack on "The effects of hepatic dysfunction on the
metabolism of methadone". I attach a copy of this document for your information. This was
distributed on 26 January 2021 to all staff within the organisation who have a clinical role in relation
to the treatment of substance misuse. Whilst the document as a whole is relevant to the concerns
raised, I highlight particularly the recommendations for staff at page 6 of the document which
include the following:
" • start low and go slow with methadone titrations"
" • obtain a copy of the Summary Care Record (SCR) from the GP Practice prior to the Initial
Medical Assessment {IMA}"
" • Consider the LFT results and other biochemical tests from the GP but understand their
limitations: they should not be viewed in isolation. In general in the context of LFTs and other
biochemical tests, drug modification in liver disease should be considered if
o the prothrombin time >130% of normal or
o if bilirubin >100µmol/L"
" • Ensure the client understands how to recognise symptoms of liver dysfunction and
clinicians can recognise them. If they present review the client as a matter of urgency and
respond appropriately"
2) We are producing a Multiple Choice Question (MCQ) assessment of the educational support pack
referred to in point 1. This assessment will be rolled out at the end of March 2021 and will be
monitored through the clinical supervision structure to ensure that the learning has been cascaded
and embedded through all relevant sections of the organisation.
(Clinical Director) and
3)
(Chief Pharmacist) hosted a clinical session
on prescribing Opioid Substitute Treatment (OST) (which includes methadone) safely on Thursday 14
January 2021. In attendance at this session was at least one clinician and one operational
representative from every service under the Turning Point umbrella with the aim that that clinician
then cascaded the learning within their own service (please see point 4 for further support for this
process). Key points from this session included:
• Ensuring a Summary Care Record (SCR) is available at the Initial Medical Assessment
•
(IMA) by requesting as early as possible from the GP Practice
If a SCR is not available at the IMA, prescribers should follow up any clinical concerns
presented at the IMA with the GP Practice prior to prescribing. Please note the
absence of an IMA does not preclude prescribing but prescribers must make a case-
by-case judgement based on the presentation and its clinical complexity.
TURNING POINT IS A REGISTERED CHARllY, NO. 234887, A REGISTERED SOCIAL LANDLORD AND A COMPANY LIMITEO BY GUARANTEE NO. 793558 (ENGLAND & WALES
REGISTERED OFFICE: STANDON HOUSE, 21 MANSELL STREET, LONDON, El SAA.
E!Jrll disability
m!i confident
COMMITTED
IN\'ESTOR IN PEOPLE
CHIEF EXECUTIVE:
TURNING
POINT
inspired by possibility
Turning Point
The Exchange
3 New York Street
Manchester
M14HN
www.turning-point.co.uk
• Titration schedules must be reflective of the clinical case and not necessarily the
same for all clients
4) The Turning Point Public Health and Substance Misuse Senior Clinical Governance Group published
within their January 2021 monthly clinical brief a reminder to all clinical staff on prescribing OST
safely. I attach a copy of this document for your information. You will see that the key areas included
in this brief which are relevant to your concerns reflect those as set out in point 3 above.
5) Turning Point will carry out a national audit across all substance misuse services in relation to the
medical information available to an OST prescriber at the point of prescription and the
documentation of considerations/actions taken pending receipt of background information. This
audit will take place in June 2021 to assess the impact of the learning as set out above.
6) We have made arrangements to provide every team within the organisation with an NHS.net
email address. The work was completed on 14th October 2020. This ensures that data can be shared
securely and efficiently between Turning Point and NHS bodies/employees (such as a GP surgery).
I hope that the above has provided the necessary reassurances following your concerns. Thank you
for raising them and I hope that I have demonstrated that Turning Point takes very seriously any
concerns that are raised about the care and treatment of its service users.
Please do let me know on the details below if any of the above fails to provide the necessary
reassurance or if it would assist to discuss any aspect further.
Yours sincerely
Medical Director
Turning Point
Enclosures:
1) Educational support pack: "The effects of hepatic dysfunction on the metabolism of methadone"
2) Public Health and Substance Misuse Senior Clinical Governance Group January 2021 clinical brief
TURNING POINT IS A REGISTERED CHARITY, NO. 234887, A REGISTERED SOCIAL LANDLORD AND A COMPANY LIMITED BY GUARANTEE NO. 793SS8 (ENGLAND & WALES
REGISTERED OFFICE: STANDON HOUSE, 21 MANSELL STREET, LONDON, El SAA.
Glrl disability
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COMMITTED
l!'.\" ESTOll IS PEOPLE
CHIEF EXECUTIVE:
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