Prevention of Future Deaths reports · 2021
Regulation 28 report to prevent future deaths, reference 2021-0160, written 18 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 | 18 May 2021 |
|---|---|
| Reference | 2021-0160 |
| Deceased | Bruce Houghton |
| Coroner | Joanne Kearsley |
| Coroner area | Manchester North |
| Category | Community health care · Alcohol, drug and medication related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 3 |
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. Secretary of State for Health
2. Manchester Health and Social Care Partnership
3._ The Uplands Medical Practice
CORONER
| am Joanne Kearsley, Senior Coroner for the Coroner area of Manchester North
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 17" August 2020 | commenced an investigation into the death of Bruce Lee Houghton the
Inquest concluded on the 30" April 2021.
CIRCUMSTANCES OF DEATH
1. Mr Houghton had a number of significant physical health issues. He was prescribed
Olanzapine, Ramipril, Atorvastatin, Co-Codamol, Fluoxetine, Omepraxole and Metformin.
Due to memory issues his medication was kept locked away from him and he would be given
this by his carers. In addition to his prescribed medication he had developed an addiction to
butane gas and due to his levels of pain he would regularly purchase over the counter-
medications which he would take an excess of, partly due to his memory loss. The evidence
before the court was that if the GP had been aware of the amount of paracetamol the
deceased was purchasing then this would have led to her considering whether he required
the co-codomol prescription, which he had been receiving for years and whether further
investigation as to his pain was required.
Mr Houghton died.on the 16'" April 2020 at his home address. His medical cause of death was due
to 1a) Combined Drug toxicity with the toxicology report indicating he had an excess of paracetamol
levels which in turn had likely led to damage to his liver causing his other medications to accumulate.
There was no evidence he intended to end his life and a conclusion of misadventure was recorded.
al
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:-
2. The Court heard the deceased had not had his annual medication review. The court heard
evidence that at these reviews the patients are not asked about any over the counter
medication they may purchase in addition to their prescribed medication.
+
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.
YOUR RESPONSE
You are under a duty to respond to this report within 56 days of the date of this report, namely
12/07/2021. |, 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.
©
COPIES and PUBLICATION
| have sent a copy of my report to the Chief Coroner and to the following Interested Persons namely:-
The family of Mr Houghton
{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 from. He may
send a copy of this report to any person who he believes may find it usefulor 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: 1%°5 21 Sign
3 responses 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.
From Maria Caulfield MP Parliamentary Under Secretary of State for Primary Care and Patient Safety 39 Victoria Street London SW1H 0EU Miss Joanne Kearsley HM Senior Coroner, Manchester North HM Coroners Court Floors 2 and 3, Newgate House Newgate Rochdale OL16 1AT 22 November 2021 Dear Miss Kearsley, Thank you for your letter of 18 May 2021 addressed to the Secretary of State for Health and Social Care, received by this Department in August 2021, about the death of Bruce Lee Houghton. I am replying as Minister with responsibility for Primary Care and I am grateful for the additional time in which to do so. Firstly, I would like to say how sorry I was to read the circumstances of Mr Houghton’s death and I offer my sincere condolences to his family and loved ones. In preparing this response, Departmental officials have brought your concerns to the attention of NHS England and NHS Improvement (NHSEI). I am advised that GP practices are expected to review patient medication on a regular basis as part of the primary medical services provided under the GP contract. In addition, Primary Care Networks (PCN’s) are required under the Network Contract Directed Enhanced Service1, to offer Structured Medication Reviews to patients. Guidance on the requirements is available2, and sets out how patients should be identified and how Structured Medication Reviews may be implemented. You may wish to note that the guidance does not specifically state these must be annual reviews. Structured Medication Reviews are a National Institute for Health and Care Excellence (NICE) approved clinical intervention to help people who have complex or problematic 1 NHS England » Network Contract Directed Enhanced Service (DES) Contract Specification 2020/21 – Primary Care Network Entitlements and Requirements 2 NHS England » Structured medication reviews and medicines optimisation polypharmacy. They are designed to be a comprehensive and clinical review of a patient’s medicines and detailed aspects of their health. They are delivered by facilitating shared decision-making conversations with patients aimed at ensuring that their medication is working well for them. Structured Medication Reviews should be holistic and personalised, tailored around the patients’ clinical and individual needs. The health literacy and holistic needs of the patient should be taken into account, and Structured Medication Reviews should consider all the medicines a patient is taking or using. NHSEI has also published advice on the role of clinical pharmacists working with PCN’s in facilitating Structured Medication Reviews3. I am aware that the Uplands Medical Practice, Whitefield, has advised in its response to your report that it has introduced a standardised medication review template that includes a prompt to routinely trigger an enquiry as to whether the patient is taking any over-the- counter medicine. I also note that the Greater Manchester Health and Social Care Partnership is supporting the Medical Practice to make sure that medication reviews are consistently and regularly carried out, and taking steps to ensure the learning from Mr Houghton’s death, is shared across Greater Manchester, including the importance of patients receiving a Structured Medication Review conducted by GPs or PCN pharmacists. I hope this response and these actions address your concerns in this area. MARIA CAULFIELD 3 NHS England » Structured medication reviews and medicines optimisation
Greater Manchester Health and Social Care Partnership
4th Floor
3 Piccadilly Place
London Road
Manchester M1 3BN
Date: 9th July 2021
Ms J Kearsley
HM Coroner
Newgate House,
2nd & 3rd Floors,
Newgate,
Rochdale,
OL16 1AT
Dear Ms Kearsley
Re: Regulation 28 Report to Prevent Future Deaths – Bruce Lee Houghton
16/04/21
Thank you for your Regulation 28 Report dated 19/04/21 concerning the sad death
of Bruce Lee Houghton on 16/04/21. Firstly, I would like to express my deep
condolences to Bruce Lee Houghton’s family.
The inquest concluded that Bruce’s death was a result of 1a) Combined drug toxicity
with the toxicology report indicating that he had an excess of paracetamol levels
which in turn had likely led to damage to his liver causing his other medications to
accumulate.
Following the inquest you raised concerns in your Regulation 28 Report to Greater
Manchester Health and Social Care Partnership (GMHSCP) that there is a risk future
deaths will occur unless action is taken.
This letter addresses the issues that fall within the remit of GMHSCP and how we
can share the learning from this case.
This matter has been discussed by the Greater Manchester Medicines and
Guidelines Sub-group (MGSG) on the 28th June 2021.
MGSG considered:
• What guidance is in place to prevent reoccurrence:
o There is a Greater Manchester Opioid and Gabapentinoid toolkit
available and about to be approved.
o NICE guidance on chronic
painhttps://www.nice.org.uk/guidance/ng193, whichsuggests many
other options to pharmacological management
• Perception of limited accessibility to healthcare in Covid and post Covid times.
N.B. this death occurred in the first month of the first lockdown.
• Communication between community pharmacy, carers and GP practices
• What factors can be implemented at a system level and which are for local
implementation. e.g. awareness, communication, training, changes of
behaviour for healthcare professionals, shared decision making with patients,
potential safeguarding issues/ care concerns.
This case will be referred through other Greater Manchester health and social care
forums (including quality groups, primary care board, medical executive) to gain
wider lessons and cascade learnings.
Key outcomes from the MGSG
The following is generic GM advice or support, some specific to the case, to prevent
future potential harm, acknowledging that this harm cannot be fully eliminated, but
the likelihood can be reduced.
MGSG noted the timing which coincided with the early stages of the first lockdown
during which there may have been a perceived lack of access to primary care. This
may have had a potential part in Mr Houghton’s ability or willingness to access his
practice to discuss pain relief if not well controlled.
Next steps
• GM Medicines Management Group (GMMMG) to provide advice and
guidance for local teams to implement, including support to ensure shared
decision making with patients and medication reviews occurring on an ideally
annual (or sooner if required) basis.
• Communication out to all relevant providers to refresh on the range of
materials which would be of use to prevent a future occurrence:
o GM polypharmacy resource pack, GM Neuropathic Pain Guidance GM
o
Opioid Resource Pack GM Antipsychotics in dementia
In addition the full range of resources available at www.gmmmg.nhs.net
and NICE etc.
o NICE guidance on chronic pain https://www.nice.org.uk/guidance/ng193,
which as noted above, suggests many other options to pharmacological
management
• The importance of patients receiving a structured medication review will be
reiterated, with confirmation that these can now take place in a number of
ways.
o Primary care network (PCN) pharmacists as well as GPs in practice can
now carry out medicine reviews so accessibility has improved.
o PCN mental health workers are expected to be able to identify patients
in need of a medicine review and signpost to their GP practice (this is in
place in many practices with the number growing all the time)
• Communication between the patient and health and social care professionals
may not have been optimal at the time due to Covid, however opportunities
appear to have been missed. There are a number of factors to action in
relation to this:
o Culture needs to be reflected upon.
o Local implementation of guideline awareness, communication, training,
changes of behaviour for healthcare professionals and carers, and
implementation of shared decision making with patients.
• There are potential safeguarding issues/ care concerns, which will be subject
to further review.
• Facilitating shared learning between healthcare professionals and
organisations.
GMHSCP is in contact with The Uplands Medical Practice to ensure that the
appropriate processes are in place and have been followed with respect to this case.
This includes any learning to ensure that medication reviews are consistently and
regularly carried out by the practice.
Actions taken or being taken to prevent reoccurrence across Greater
Manchester.
1. Learning to be presented/shared with the Greater Manchester Quality Board.
This meeting is attended by commissioners, including commissioners of
specialist services, regulators, Healthwatch and NICE.
2. Communication to all relevant providers to share appropriate advice and
guidance and increase staff awareness regarding the range of materials that
are already available.
3. Shared learning from this and similar cases at Greater Manchester and
borough level will be cascaded to professionals through relevant governance
and learning forums.
4. Potential safeguarding issues/ care concerns to be subject to further review.
In conclusion, key learning points and recommendations will be monitored to ensure
they are embedded within practice. GMHSCP is committed to improving outcomes
for the population of Greater Manchester.
I hope this response provides the relevant assurances you require. 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
Dr
Chair of GM Medical Executive, GMHSCP
www.theuplandsmp.nhs.uk Bury New Road, Whitefield, M45 8GH Date: 3rd August 2021 IN THE CORONER AREA OF MANCHESTER NORTH THE INQUEST TOUCHING UPON THE DEATH OF BRUCE LEE HOUGHTON WITNESS STATEMENT OF DR I, Dr of The Uplands Medical Practice, Whitefield Health Centre, Bury New Road, Whitefield, Manchester, M45 8GH make this statement in response to a Regulation 28 Report to Prevent Future Deaths made by Ms Joanne Kearsley Senior Coroner for the Coroner area of Manchester North in relation to the inquest of Bruce Lee Houghton: 1 2 3 I am a GP Partner at The Uplands Medical Practice (‘the Practice’) and I have been a GP at the Practice for 4 years. I am providing this response on behalf of the Practice. I am also now the Mental Health and Safeguarding Lead for the Practice. Ms Kearsley specified in the Regulation 28 report that her concern related to the fact that the Court heard that the deceased had not had his annual medication review and that the Court heard evidence that at these reviews the patients were not asked about any over the counter medication they may purchase in addition to their prescribed medication. The findings of the inquest highlighted the importance of information sharing between social care and health care providers. Since Mr. Houghton’s sad death significant progress has been made in embedding and referring to integrated teams, and the Practice participates in monthly multidisciplinary team meetings which includes mental health teams, social care, and other providers. The members of the Practice team are encouraged to refer any individuals where this input would be of benefit, and referrals can also be made by social care partners. A network pharmacist attends these meetings and will complete medication reviews as required for any individuals of concern. He works across 4 practices in the Whitefield and District Unsworth Primary care network and neighbourhood. 1 Bury New Road, Whitefield, M45 8GH www.theuplandsmp.nhs.uk 4 5 6 7 8 9 10 11 A change that has already been implemented at the Practice is that patients who are seen as vulnerable will be seen by more permanent senior GPs and clinicians rather than locum GPs whenever possible to preserve continuity of care in patients that need it the most. Another change that has already been implemented at the Practice since Mr. Houghton’s death is that clinical staff can place restrictions on prescriptions using the current IT system to prevent patients from over ordering medication. This update was covered in a clinical meeting in February 2021 and included in the prescribing policy which is shared with new clinicians on induction and available on the Practice shared portal. The Practice is in the process of creating a standardised medication review template based on good medical practice which will include a prompt to routinely trigger an enquiry as to if the patient is taking any over the counter medication, or supplements at the point of prescribing and at annual reviews. The clinical staff at the practice will all be made aware that they are to complete this questionnaire when prescribing new medication to a patient or when they are conducting a medication review. This questionnaire will be shared with the 3 other GP practices that are involved in the multidisciplinary team and will also be shared with Manchester Health and Social care Partnership for their views to see if it can be improved in any way and to promote good practice. I have already liaised with Manchester , Senior Primary care Manager Health and Social Care Partnership to ask for their support and for Quality Improvement across Greater Manchester has informed me she will investigate how they can assist. Once this feedback has been received the Practice will look to embed the questionnaire within the current clinical system (Vision) although due to its limitations this may not be possible until the Practice moves to a new clinical system. A date for sharing this has not yet been scheduled, but a slot on the next neighbourhood team meeting in September 2021 will be requested subject to other items on the agenda. The Practice along with all the practices in Bury is in the process of moving to a new clinical IT system and it is our understanding that this has integrated prompts to improve the prescribing safety. This should assist staff who are prescribing in when it is appropriate to conduct a medication review and provide visual reminders. The Practice is due to have the new system in place by March 2022. The Practice has already employed a permanent salaried GP who has been in post since May 2021 and has 3 more permanent salaried GPs set to join the practice in August 2021. The medication review questionnaire and when it should be used will be included in the Practice’s prescribing policy and in-house Practice training on conducting a good medication review will be set up which I will lead. I will be assisted by the Practice manager. The first training on this will occur once the new GPs are in post. The training will also be provided for all new staff as part of their induction, and they will be asked to review the Practice’s prescribing policy. The practice aims to share this fully for feedback at the next practice meeting in August 2021 (17th August 2021) with a view to implementing it thereafter. The Practice has employed a permanent pharmacist who is set to join in October 2021, after a thorough competency-based interview which specifically included questions about competency in conducting medication reviews and if they were routinely enquiring about over the counter medications as part of these. This was important to the Practice to ensure the pharmacist understands the goals of the Practice. The permanent pharmacist will then have an influence on the prescribing policy and the medication 2 Bury New Road, Whitefield, M45 8GH www.theuplandsmp.nhs.uk 12 13 14 15 16 review questionnaire which can be updated and improved whenever necessary. This will also improve continuity of care. If the Practice receives information regarding a patient from other organisations or staff members that cause concern, then that patient will be invited for a review by a doctor. As the mental health lead, I regularly attend the Neighborhood MDT meetings which allows for those patients with serious mental health conditions or flagged as vulnerable to be reviewed at the Practice by me as part of the actions with input from the network pharmacist allowing for a more detailed (structured) medication review. Staff at the Practice are aware of the importance of flagging any patients that may be causing concern, and these are flagged to me or the on-call GP in my absence. The Practice has since May 2021 started daily informal clinical huddles and this has been working well in sharing information about patients that may require review or further input. This has helped improve communication internally in sharing information and follow up of patients that may need more urgent input. As part of the Covid recovery the Practice is in the process of sending out invites as part of the recall system. The Practice will prioritise the completion of a detailed structured medication review for all patients with serious mental health conditions as defined in the Quality Outcomes Framework (QOF). Mr. Houghton would have been included in this group of patients. As the Mental Health Lead for the Practice, I will have oversight of this process. A dedicated member of staff will manage this, and the Practice is looking to train up a mental health champion to support this. We expect to have this in place by the end of August 2021. The higher risk mental health patients will be invited for a health check first and then subsequently all patients with known mental health conditions will be invited for a medication review. The Practice will aim to complete medication reviews of the higher risk patients with serious mental health conditions by the end of December 2021 with all patients having completed this by March 2022. An electronic document will be created as a safety net to priortise these patients and reviewed monthly with the support of a mental health champion to ensure the patient has a health check followed by a medication review with a GP or pharmacist. This document will be completed by the end of August 2021, and a traffic light system will be used to identify patients needing urgent, medium, and less urgent reviews in order of priority. A dedicated member of the administration team will support the review and booking of these patients and follow up when the patient does not engage. Any individuals causing concern will then be flagged to the neighbourhood team meeting. The Practice pharmacist will be an excellent resource for this The Practice is engaging the practice development support of the Royal College of GPs to review the Practice processes currently in place and the plans shared above, for feedback and review. I would be happy to provide a further update to the coroner regarding the progress in November 2021 if that is acceptable. I will encourage the new clinicians to complete continued professional development focusing on specific areas so that the practice has a broad range of specialist knowledge, and this will assist in treating more vulnerable patients and patients with long term health issues. 3 www.theuplandsmp.nhs.uk I believe that the facts stated in this witness statement are true. Bury New Road, Whitefield, M45 8GH Signed: DR Date: 3rd August 2021 4
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