Prevention of Future Deaths reports · 2021
Regulation 28 report to prevent future deaths, reference 2021-0224, written 5 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 | 5 May 2021 |
|---|---|
| Reference | 2021-0224 |
| Deceased | Sarah Brady |
| Coroner | Joanne Lees |
| Coroner area | Black Country |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths · Alcohol, drug and medication related deaths · Mental Health related deaths · Community health care · 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 (1)
REGULATION 28 REPORT TO PREVENT FUTURE DEATHS
THIS REPORT IS BEING SENT TO:
1. Sandwell and West Birmingham Hospital Trust
1
CORONER
I am Mrs Joanne Lees, Area Coroner, for the coroner area of The Black Country
Jurisdiction.
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 6/11/20 I commenced an investigation into the death of Sarah Brady dob 26/1/45.
The investigation concluded at the end of the inquest on 5/5/21. The conclusion of the
inquest was Suicide. The medical cause of death was recorded as 1a) Multiple Organ
Failure, 1b)
overdose 2) Stroke and Depression.
The inquest found and recorded the following facts;
On 4/8/20 the deceased, a 75-year-old lady was admitted to hospital having been
found unresponsive following a presumed overdose of
mortem toxicology tests revealed significant concentrations of
. Ante
. Despite treatment with antidotes and antibiotics, she continued to
deteriorate and went into multi organ failure and sadly passed away in hospital on
8/8/20. Mrs Brady had a historical diagnosis of depression and PTSD and more recently
functional neurological disorder with longstanding chronic back pain. She had a history
of intentional medication overdose in March 2020 and had recently self-discharged
from hospital 3 days before this admission. Mrs Brady was in possession of a
significant amount of prescription medication at the time of her death and there was
evidence of recent deterioration in her mental and physical health in the weeks leading
up to her death.
4
CIRCUMSTANCES OF THE DEATH
Mrs Brady was a 75 year old lady admitted to City Hospital, Birmingham on the evening
of 4/8/20 having been found unresponsive at home following a presumed overdose
(
). She had Multiple recent hospital admissions with back pain,
abdominal pain, headache and photophobia and had Self-discharged from hospital on
01/08/2020 following an admission with back pain; underwent an MRI spine and was
,
discharged with analgesia. A urine toxicology screen from was positive for
1
. Blood Paracetamol
levels were less than 10 mg/l and blood salicylate levels were less than 50 mg/l. Her
blood ethanol level was < 100 mg/l (not detectable). She was treated with Naloxone
and antibiotics for an aspiration pneumonia. Quantitative toxicology results from
admission showed
,
and
. All of these
were consistent with the diagnosis of significant
overdose. Given the response to extra doses of antidote the rate of the Naloxone and
Flumazenil infusions were increased. Mrs Brady deteriorated into multi organ failure
despite treatment and on the afternoon of 8/8/20 the Naloxone and Flumazenil
infusions were discontinued at 12:57 hours and Mrs Brady passed away in hospital
shortly afterwards.
CORONER’S CONCERNS
5
During the course of the inquest the evidence revealed matters giving rise to concern.
In my opinion there is a risk that future deaths could 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) Mrs Brady had a long history of Chronic pain, mental health problems and informal
admissions in Psychiatric hospitals. She had a recent history of intentional medication
overdose in March 2020 and erratic compliance with her medications.
(2) Due to the above, Mrs Brady’s GP was only issuing 7 day prescriptions due to her
high risk of overdose in order to limit medication availability. This included
amongst others.
(3) Mrs Brady had already been issued with a prescription by her GP on 14/7/20 for her
regular prescription medication;
(4) The inquest heard evidence that following a hospital admission in early July 2020,
Mrs Brady was medically fit for discharge on 15/7/20 and a prescription was issued by
the Sandwell & West Birmingham Hospital Trust for 14 days of
(4) It was unclear from the evidence whether the prescription had actually been
fulfilled by the hospital. I am concerned that Mrs Brady was issued with a prescription
in excess of 7 days and for medication that had already been prescribed to her by her
GP only the previous day and against a background of overdose and erratic compliance
with her medications;
(5) The levels of
found as a result of qualitative
testing appeared to be well in in excess of her prescriptions and there was evidence
that Mrs Brady may have been stockpiling medication. It is possible that the additional
prescription, if supplied may have formed part of the medication taken by way of
overdose.
(6) I heard at inquest that another similar prescription issued on 28/7/20 following a
further admission had NOT been fulfilled.
6
ACTION SHOULD BE TAKEN
In my opinion action should be taken to prevent future deaths and I believe your
organisation has the power to take such action.
2
7
YOUR RESPONSE
You are under a duty to respond to this report within 56 days of the date of this report,
namely by 2/7/21. 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
(daughter of the deceased).
Persons
I am also under a duty to send a copy of your response to the Chief Coroner and all
interested persons who in my opinion should receive it.
I may also send a copy of your response to any other person who I believe may find it
useful or of interest.
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.
9
5/5/21
Joanne M. Lees Area 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.
Sandwell General Hospital
Lyndon
West Bromwich
B71 4HJ
Legal Services Department
Mrs J Lees
Area Coroner
Black Country Coroner’s Court
Jack Judge House
Oldbury
West Midlands
B69 2AJ
28 June 2021
Dear Mrs Lees,
RE: Regulation 28 Report – Sarah Brady
I am in receipt of your Regulation 28 Report following the Inquest and your ruling on 5 May
2021, in respect of the late Mrs Sarah Brady.
During the collation of information for the inquest, it was recognised that the frequent
attendance and associated discharge processes, including provision of medication, may
highlight that there might be an oversupply to an already vulnerable person. I am sorry we
missed the opportunity to provide you with this evidence. This was, in fact, not the case.
You will see from the attached list that, apart from the Aspirin, dispensed on 29 July 2020,
medications were supplied for 7 days, 5 days or were not dispensed at all, instead giving
back her own medications. The Aspirin was a new medication so was supplied to the level
agreed with the CCG and in total only provided 2.1g, where the maximum daily dose for pain
control is 4g.
I understand from those present at the inquest hearing, that Mrs Brady was known to stock
pile medications, clearly both we and her GP were managing the complexity of providing
medications to treat her ailments, at the same time as trying not to over provide medicines to
a clearly vulnerable person.
Given the information we provided at the Inquest and the attached evidence, I believe we
were not over supplying Mrs Brady.
My colleague,
provide advice or further details on our actions. She can be contacted on
through
, Deputy Director of Governance, would be best placed to
or
Yours sincerely,
Interim Chief Executive
cc.
(daughter of Mrs Sarah Brady)
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