Prevention of Future Deaths reports · 2021
Regulation 28 report to prevent future deaths, reference 2021-0053, written 25 Feb 2021. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 25 Feb 2021 |
|---|---|
| Reference | 2021-0053 |
| Deceased | Andrew Biddlecombe |
| Coroner | Jason Pegg |
| Coroner area | Hampshire, Portsmouth and Southampton |
| Category | Community health care · Road (Highways Safety) 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.
Christopher Campbell Wilkinson Senior Coroner for Hampshire, Portsmouth and Southampton Regulation 28: REPORT TO PREVENT FUTURE DEATHS (1) NOTE: This from is to be used after an inquest. REGULATION 28 REPORT TO PREVENT DEATHS THIS REPORT IS BEING SENT TO: Emsworth Surgery 1 2 …………………………………… 3 …………………………………… 1 CORONER I am Jason PEGG, Area Coroner for the area of Hampshire, Portsmouth and Southampton 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 16/07/2020 10:57 I commenced an investigation into the death of Andrew BIDDLECOMBE aged 70. The investigation concluded at the end of the inquest on 25/02/2021 00:00. The conclusion of the inquest was: 1a Severe Head and Neck Injuries 1b Road Traffic Incident 1c II 4 CIRCUMSTANCES OF THE DEATH The deceased died on 10th July 2020 at Portsdown Hill Road, Bedhampton, Hampshire. The deceased was driving a convertible motor car in the opposing carriageway when the nearside front of the motor car collided with a sign-post causing the motor car to roll over causing the deceased fatal injury to the head and neck. The deceased made no attempt to slow down or steer away from the sign-post, it cannot be ascertained whether the deceased suffered a medical episode or whether the deceased's poor eyesight and mobility hindered the deceased in avoiding the collision. The deceased's pre-existing medical conditions contributed to the death. 5 CORONER’S CONCERNS Coroner’s Office, 1 Guildhall Square, Portsmouth, PO1 2GJ Tel: 023 9268 8326 Email: coroners.office@portsmouthcc.gov.uk Christopher Campbell Wilkinson Senior Coroner for Hampshire, Portsmouth and Southampton The MATTERS OF CONCERN are as follows: The deceased was 70 years of age. The deceased had several medical conditions including Parkinson’s disease; had suffered possible epileptic seizures; had bilateral posterior capsular opacity. The deceased was known to have problematic double vision and was partially sighted in his right eye. The deceased was known to have poor mobility. The deceased was prescribed medications namely Ipinnia XL a medication with a recognised side-effect of sudden sleep onset episodes and Ramipril a medication with recognised side-effects of blurred vision, confusion and dizziness. It was known that the deceased was a current driver, noting the Parkinson’s review in February 2020. The deceased had not been advised of the impact of his medical conditions on his ability to drive safely nor had he been advised of the legal requirement to notify the DVLA of his medical conditions. The practice did not inform the DVLA of the deceased’s medical conditions relevant to the deceased’s ability to drive safely. 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you and your practice 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 April 22, 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 who may find it useful or of interest. 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 Coroner’s Office, 1 Guildhall Square, Portsmouth, PO1 2GJ Tel: 023 9268 8326 Email: coroners.office@portsmouthcc.gov.uk Christopher Campbell Wilkinson Senior Coroner for Hampshire, Portsmouth and Southampton Jason PEGG Area Coroner for Hampshire, Portsmouth and Southampton Dated: 25/02/2021 Coroner’s Office, 1 Guildhall Square, Portsmouth, PO1 2GJ Tel: 023 9268 8326 Email: coroners.office@portsmouthcc.gov.uk
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.
Emsworth Surgery
6 North Street . Emsworth . Hampshire . PO10 7DD
www.emsworthsurgery.co.uk
Ms Julie Davies
Coroner’s Officer
Portsmouth Office
The Coroner’s Court
1 Guildhall Square
Portsmouth
PO1 2GJ
16th July 2021
Requested Report -
Mr Andrew Biddlecombe (AB) was diagnosed with Parkinson’s Disease in 2012. He was advised
by the Parkinson’s Nurse Specialist of his responsibility to inform the DVLA of his diagnosis
verbally during a clinic appointment in 2012. AB was sent a copy of the clinic letter detailing this
advice.
AB had two possible seizures documented in the past dating back to 2012. He was informed by a
consultant neurologist verbally during a clinic appointment following the first seizure that he had
a duty to inform the DVLA and his insurance company. AB was also sent copy of this clinic letter.
Emsworth Surgery completed a DVLA Medical Questionnaire in 2014. His diagnosis of Epilepsy
was declared on this DVLA form as was his diagnosis of Parkinson’s Disease. His driving status
and neurological symptoms continued to be reviewed at regular six-month intervals in the
neurology clinic at St Richard’s Hospital up until the time of his death. His last clinic appointment
letter referred to him as “a very fit and active gentleman”.
AB also had cataracts that were operated on in 2019 and at his last ophthalmology review in
February 2020 he was noted to have posterior capsule opacities which were due to be treated.
The letter from this appointment does not state he was not advised to drive or that there was any
concern that he did not meet the visual standards for driving.
With regards to medication that may have had an impact on driving, AB was commenced on
Ropinirole in 2012, and he remained on this medication up until the time of his death. Hospital
letters over this period document regular medication reviews as part of his care.
Page 2:
.
Contd/…….
Emsworth Surgery
Hospital correspondence, in at least the two years prior to his death, document that he was sent
a patient medication leaflet along with a copy of his clinic letters detailing the possible side effects
of this drug with particular regard to its potential for sudden drowsiness and impact on safe
driving.
He was also on a low dose of Ramipril at the time of his death, this had been commenced in late
2019. He attended for a medication review several weeks after commencing this and there were
no reported side effects at the review appointment nor any reported in the months after this.
Emsworth Surgery have undertaken a significant event analysis as part of the action arising from
the Regulation 28 Report received. We have reviewed the templates that could be used for
chronic disease review to ensure there are questions relevant to the patient’s driving status. We
have also written to all our patients on the Epilepsy and Parkinson’s Disease register to remind
them of their responsibilities to inform the DVLA of their diagnosis. We have asked the patients
on these registers to inform us if they are current drivers so we can ensure their records are up
to date. Finally, we have sent a medication leaflet to all patients on Ropinirole detailing possible
side effects including sudden drowsiness to remind patients of these and the importance of
reporting side effects.
With kind regards,
Dr
.
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