Prevention of Future Deaths reports · 2021
Regulation 28 report to prevent future deaths, reference 2021-0190, written 2 Jun 2021. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 2 Jun 2021 |
|---|---|
| Reference | 2021-0190 |
| Deceased | Steven Allen |
| Coroner | Alison Mutch |
| Coroner area | Greater Manchester South |
| Category | Community health care · Alcohol, drug and medication 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 REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: Stockport Clinical Commissioning Group. 1 CORONER I am Alison Mutch, Senior Coroner, for the Coroner Area of Greater Manchester South. 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 26th October 2020 I commenced an investigation into the death of Steven Allen. The investigation concluded on the 24th May 2021 and the conclusion was one of drug related death. The medical cause of death was combined drug toxicity. 4 CIRCUMSTANCES OF THE DEATH On 25th October 2020 Steven Terence Allen was found unresponsive at his home address, 26 Dunton Towers. Police investigation found no suspicious circumstances and no evidence of third party involvement in his death. Post mortem examination included toxicology. Toxicology found that he had a fatal level of prescribed medication in his system. 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. – The inquest heard evidence that he had a chaotic lifestyle and a history of drug addiction. He was in significant pain and was prescribed medication to manage his pain including oxycodone. He was prescribed this and additional medications although there was a history of addiction, self-harm and poor use of prescribed and illicit substances. Prescribing of these medications was done through telephone consultations due to Covid 19 and on occasion additional replacement prescriptions were given with little challenge. 6 ACTION SHOULD BE TAKEN 1 In my opinion action should be taken to prevent future deaths and I believe you 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 28/07/2021. 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 namely Mr John Allen (family of the deceased), 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 Dated: 02/06/2021 Signature: Alison Mutch HM Senior Coroner South Manchester 2
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.
NHS) Stockport Clinical Commissioning Group 4th Floor Stopford House Piccadilly Stockport SK1 3XE 07 July 2021 DB a 12 JUL 2021 HM CORONER MANCHESTER SOUTH Private & Confidential Ms Alison Mutch H M Senior Coroner Coroner's Court 1 Mount Tabor Street Stockport SK1 3AG Dear Ms Mutch Steven Allen I refer to the Regulation 28 Prevention of Future Deaths Report relating to the above named and thank you contacting NHS Stockport Clinical Commissioning Group (CCG) in this matter. I am sorry to learn of the death of Mr Allen and would ask that you pass on my sincere condolences to his family at this difficult time. You explain that Mr Allen had a chaotic lifestyle and a history of drug addiction and raise concern that despite this history, medication including Oxycodone, were prescribed via telephone consultation due to Covid 19 and on occasion replacement prescriptions were given with little challenge. The Practice take on board the comments included within the Regulation 28 Report and have undertaken a review of this case and looked at their processes for the management of prescribing for patients in this vulnerable cohort. The practice are satisfied that this was an isolated case and that all clinicians do adhere to guidance in relation to informed prescribing and support of this patient group. As the commissioners of healthcare services for the Stockport population, Stockport CCG is keen to ensure that we learn from patient experience and consistently improve the services we provide. In response to this case I can confirm that the following steps are in place to address the issue highlighted in this case:- e We acknowledge that drugs causing addiction is a system wide healthcare challenge in Stockport and nationally. I can confirm that the review of high opioid prescribing and other drugs causing addiction has been highlighted in the national DES contract. e The Medicines Management Team is currently in discussion with the Primary Care Network (PCN) Leads to explore how the Stockport Integrated Pharmacy Service (SIPS) can support GP Practices in optimising medication reviews for this patient cohort. e There are currently also resources available within Primary Care to support practices with high opioid prescribing; these are as follows: - Greater Manchester Medicines Management Group (GMMMG) Opioid Prescribing for Chronic Pain: Resource Pack Inappropriate Polypharmacy Review and Treatment Optimisation: Resource Pack Stockport GPs will be reminded of the availability of these resources and how to seek support in the next pharmacy newsletter. I do not under estimate the impact of addiction on any individual and/or their family and whilst I am mindful that I cannot undo what happened in this case, I hope Mr Allen’s family will be reassured that steps are being taken to support our GPs in the prescribing of medications linked to addiction. Yours sincerely b_< Medical Director
See every Prevention of Future Deaths report matching Community health care, 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.