Prevention of Future Deaths reports · 2021
Regulation 28 report to prevent future deaths, reference 2021-0148, written 10 May 2021. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 10 May 2021 |
|---|---|
| Reference | 2021-0148 |
| Deceased | Parys Lapper |
| Coroner | Penelope Schofield |
| Coroner area | West Sussex |
| Category | Mental Health related deaths · Alcohol, drug and medication related deaths · Emergency services related deaths (2019 onwards) · Hospital Death (Clinical Procedures and medical management) related deaths · Community health care and emergency services related deaths · 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: REPORT TO PREVENT FUTURE DEATHS
THIS REPORT IS BEING SENT TO:
Chief Executive
NHS England
PO Cox 16738
Redditch
B97 9PT
(1)
1
CORONER
I am PENELOPE SCHOFIELD, senior coroner, for the coroner area of WEST SUSSEX
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 INQU EST
On 24th September 2019 I commenced an investigation into the death of Parys Alan
George Lapper which concluded at the end of a 5-day inquest on 14th January 2021.
At the end of the Inquest I concluded “Parys was a young man with complex mental
health issues. From a young age he had started to develop an excessive use of illicit
substances and prescribed medications. He had been under the Child and
Adolescent Mental Health Services and transitioned to the Adult Mental Health
Services. Shortly before his death he had been discharged from the Adult
Assessment and Treatment service as he had failed to engage with them. At the
time of his death he was under the care of a private psychiatrist but there was no
active treatment or provision in place to address his misuse of prescribed
medication or illicit substances.”
Following the Inquest, I indicated that I was minded to make a Regulation 28 report but
would like to hear submissions from the Interested Persons. Submissions have since
been received from the family and those representing your Trust.
I have fully considered these submissions prior to preparing this report and I apologise
for the delay in finalising this Regulation 28 report.
4
CIRCUMSTANCES OF THE DEATH
1
Mr Lapper was 19 years old at the time of his death. He had previously been under the
Child and Adolescent Mental Health Services and had had an inpatient admission when
he was 17 years old. He later went on and transitioned to the Adult Mental Health
Services and was supported by the Leaving Care Service and the Community Mental
Health Team. Mr Lapper had a diagnosis of Attention Deficit Disorder, Post Traumatic
Stress Disorder, Poly substance Abuse and Emotional Dysregulation.
In the lead up to his death Mr Lapper was able to obtain medication from several
providers namely the Community Mental Health team, his GP, the local A&E hospital,
and a Private Psychiatrist. Providers did not carry out any checks to look out for other
possible providers (and indeed as there is no central record it appears that there is no
mechanism in place to do this) before issuing a new prescription. This meant that the
NHS did not know what a Private provider has prescribed and vice versa. This enabled
Mr Lapper to play the system and obtain duplicate prescriptions and misuse the
prescription medication.
Sadly, on 13th August 2020 Mr Lapper was found deceased in his room at the Wolsey
Hotel. The Police attended and they were satisfied that there was no 3rd party
involvement. Ambulance paramedics attended but were not able to revive him and he
was declared deceased at 1125hrs.
A post-mortem examination was carried out on 19th August and a COD was given
1a Respiratory depression
1b Opiate and benzodiazepine toxicity.
5
CORONER’S CONCERNS
During 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. –
Mr Lapper was a young man who was struggling with mental health issues. He had
become dependent on prescribed medication. He had made concerted efforts to obtain
prescribed medication, in the lead up to his death, from a number of sources.
He was able to obtain medication from the local Community Mental Health Team, his GP
and A&E at the local hospital whilst also obtaining prescriptions from a Private
Psychiatrist. During the evidence heard at the Inquest it was clear that individuals can
very easily manipulate the current prescription system. As there is no central record of
what prescriptions have been issued it appears very easy for individuals to play the
system and thereby obtain excess medication. This can lead to the risk of an individual
abusing the medication that can bring about a fatal outcome.
Whilst the GP was made aware of some of the prescriptions that had been issued there
is no mechanism in place for any provider to check what the individual has already been
prescribed with by other providers before the new prescription is issued. It appears that
the NHS and private providers act in isolation.
ACTION SHOULD BE TAKEN
In my opinion action should be taken to prevent future deaths and I believe 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 5th July 2021. I, the coroner, may extend the period.
Your response must contain details of action taken or proposed to be taken, setting out
2
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: -
Sussex Partnership Foundation Trust
Dr
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
Date 10th May 2021
Penelope Schofield, Senior Coroner
3
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.
Ms Penelope Schofield HM Senior Coroner HM Coroner Record Office Orchard Street Chichester PO19 1DD National Medical Director and Interim Chief Executive, NHS Improvement NHS England & NHS Improvement Skipton House 80 London Road London SE1 6LH 17th August 2021 Email [Insert date] Dear Ms Schofield, Re: Regulation 28 Report to Prevent Future Deaths – Parys Alan George Lapper (13/08/2020) Thank you for your Regulation 28 Report (hereafter “report”) dated 11/05/2021 concerning the death of Parys Alan George Lapper on 13/08/2020. Firstly, I would like to express my deep condolences to Mr Lapper’s family. Your report concludes Mr Lapper’s death was a result of respiratory depression and opiate and benzodiazepine toxicity. Following the inquest you raised concerns in your report to NHS England and NHS Improvement (NHS E/I) regarding the mechanisms by which individuals can obtain medications from NHS and private providers and the potential to obtain excess medication via these mechanisms, you also raised concerns regarding the capability of providers to check what has already been prescribed by another provider. Guidance issued by the General Medical Council (GMC) sets out good prescribing practice (Good practice in prescribing and managing medicines and devices), including specific references to prescriber responsibilities and ensuring prescribers have all the relevant information, including adequate knowledge of the patient’s health, before prescribing. This guidance also applies to prescribers in the private sector. There is also reference to specific considerations such as whether or not the prescriber has sufficient information to prescribe safely and has access to the patient’s medical records. The guidance referred to above is clear in setting out responsibilities for all prescribers including those working in the private sector. Furthermore, there are some key programmes of work in progress to support NHS providers to share information more effectively, which is set out below. NHS England and NHS Improvement Firstly, there is work underway to support the adoption of electronic prescribing solutions across Trusts, without which information cannot be made available for sharing. Funding has now been provided to support adoption across more than 80% of NHS Trusts so far and work is underway to fund the remaining 20%. This work will conclude by the end of 2024. Secondly, sharing medicines information requires the adoption of common information standards and work is also underway to define the necessary standards with subsequent plans in place to support adoption across health and care organisations, and these standards will be underpinned by the mandate to adopt them. The first early adopters of this programme are due to have these standards in place by the end of this financial year and the work is due to be completed by the end of 2024. This should enable a consolidated view of an individual’s medicines from numerous sources. In the shorter term, the shared record programme aims to deliver a minimum of view access by the end of this year for information that is digitally available now. The work described above is underpinned by commitments set out in the Long Term Plan to improve community mental health, so people receive the support that they need to help them stay well. All local areas have received funding to develop and begin delivering new models of care that integrate primary care and community mental health services for adults with severe mental health problems. By the end of 2023/24, all areas will have one of these models in place, with care provided to at least 370,000 adults per year nationally. These models of care will give people greater choice and control over their care and will ensure support is available for people who do not meet the existing thresholds for specialist mental health services. They will also improve access to a range of interventions and support, including psychological therapies, physical health care, employment support, medicines management and support for self-harm and coexisting substance use, with care increasingly personalised and trauma-informed. With the existing guidance for prescribers and commitments in place to increase access to and improve the quality of mental health services for people with complex mental health issues, we will work closely with local services to support them to deliver the required improvements and prevent future deaths. Finally, reducing suicide and preventing self-harm remains a priority for NHSE/I. That’s why we are working closely with partners Public Health England and the Department of Health and Social Care to support local areas to deliver multi- agency suicide prevention plans. As part of the £2.3billion settlement for mental health in the Long Term Plan, we are providing targeted and ring fenced funding to STPs so they can deliver their multi- agency plans. This includes suicide prevention activities, initiatives to prevent self- harm and putting in place postvention bereavement support. We have committed that from 2019/20 every area of the country will receive funding for suicide prevention and bereavement services, by 2023/24, from the total pot of money of £57m. To support these STPs, there is a bespoke national suicide reduction support package with the National Confidential Inquiry into Suicide and Safety in Mental Health (NCISH) and National Collaborating Centre for Mental Health (NCCMH) working together to support STPs in their quality improvement plans, as part of the national suicide prevention programme. Thank you for bringing these important patient safety issues to my attention and please do not hesitate to contact me should you need any further information. Yours sincerely, Professor National Medical Director, NHS England and NHS Improvement and Interim Chief Executive, NHS Improvement
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