Prevention of Future Deaths reports · 2021
Regulation 28 report to prevent future deaths, reference 2021-0234, written 9 Jul 2021. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 9 Jul 2021 |
|---|---|
| Reference | 2021-0234 |
| Deceased | Anita Mandalia |
| Coroner | Graeme Irvine |
| Coroner area | East London |
| Category | Community health care · Alcohol, drug and medication related deaths · Other related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | none published |
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.
MR G IRVINE
ACTING SENIOR CORONER
EAST LONDON
Walthamstow Coroner's Court, Queens Road Walthamstow, E17 8QP
REGULATION 28: REPORT TO PREVENT FUTURE DEATHS (1)
REGULATION 28 REPORT TO PREVENT FUTURE DEATHS
THIS REPORT IS BEING SENT TO:
Dr ER Newbury Group Practice, Newbury Park Health Centre,
40 a Farm Road, Ilford —_ IG2 7LE
CORONER
| am Graeme Irvine, acting senior coroner, for the coroner area of East London
CORONER’S LEGAL POWERS
| 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.
http://www. legislation.gov.uk/ukpga/2009/25/schedule/5/paragraph/7
http://www. legislation.gov.uk/uksi/2013/1629/part/7/made
INVESTIGATION and INQUEST
On 12! February 2021 | commenced an investigation into the death of Anita Mandalia
aged 58 years. The investigation concluded at the end of the inquest on 8 July 2021.
The conclusion of the inquest was that Mrs Mandalia died from:
e 1a Multi Organ System Failure
e 1b Septic Shock
e 1c Pneumonia
e ii Multiple drug overdose, depression
A short form conclusion of accidental death was arrived at
CIRCUMSTANCES OF THE DEATH
Mrs Mandalia took an overdose of prescribed medications whilst at home on 7*
February 2021. Despite medical treatment she succumbed to complications of the
overdose on 11" February 2021 in hospital.
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 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 Mandalia had been prescribed I) NICE guidance and BNF
guidance stipulates that this medication ought not to be prescribed for longer
than HM. Mrs Mandalia had received that prescription far longer that the
recommended period. The GP surgery had not reviewed the appropriateness of
that prescription.
2. Despite having received instructions within a discharge summary from a
secondary mental health trust in August 2020 that required the surgery to re-
refer Mrs Mandalia if concerns arose regarding her mental health, when issues
were raised in October and December 2020 to the surgery no referral was
made.
3. In June 2020 the surgery introduced measures to mitigate the risk of overdose
presented by Mrs Mandalia which required medication to be dispensed in a
dosette box containing a maximum 7-day supply of medications. However, on
6 January 2021 Mrs Mandalia was prescribed for
pain which allowed her access to an excess of a|
ACTION SHOULD BE TAKEN
In my opinion action should be taken to prevent future deaths and I believe you
[AND/OR your organisation] 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 by 24 September 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.
COPIES and PUBLICATION
{ have sent a copy of my report to the Chief Coroner and to the following Interested
Persons the family of Mrs Mandalia, the CQC and GMC. | have also sent it to the
Director of Public Health who may find it useful or of interest.
lam 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.
| may also send a copy of your response to any other person who | 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 | [DATE] 9" July 2021 [SIGNED BY CORONER
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