Prevention of Future Deaths reports · 2021
Regulation 28 report to prevent future deaths, reference 2021-0395, written 22 Nov 2021. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 22 Nov 2021 |
|---|---|
| Reference | 2021-0395 |
| Deceased | Michelle Jeffries |
| Coroner | Christopher Morris |
| Coroner area | Manchester South |
| Category | Alcohol, drug and medication related deaths · Community health care |
| Source | judiciary.uk record · original PDF |
| Responses published | 2 |
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: Dr , Medical Director, Trafford CCG , Interim Chief Officer, Greater Manchester Health & Social Care Partnership I 1 CORONER ' Christopher Morris, Area Coroner for 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. http://www. legislation .gov. uk/ukpga/2009/25/schedule/5/pa rag raph/7 : httg://www.l~islation.gov.uk/uksi/2013/1629/gart/7/made i 3 INVESTIGATION and INQUEST On 30th June 2021, Alison Mutch OBE, Senior Coroner, opened an inquest into the death of Michelle Jeffries who died at her home on 27th March 2021, aged 42 years. The investigation concluded at the end of the inquest which I heard on 22nd October 2021. I A post mortem examination determined that Ms Jeffries died as a consequence of the combined toxic effects of ' By way of conclusion, I recorded that Ms Jeffries died by way of an . accident. 4 CIRCUMSTANCES OF THE DEATH Ms Jeffries had a complex medical history which was associated with her experiencing chronic and debilitating pain. For many years, Ms Jeffries had been prescribed large quantities of analgesic medication, including opiates. Whilst numerous health professionals were involved in'Ms Jeffries's care over the years, and her GP Practice undertook regular medication reviews in accordance with practice procedures, the evidence before the court suggested there was a lack of involvement from pain specialists. 5 CORONER'S CONCERNS The MATTERS OF CONCERN are as follows. - It is a matter of concern that there is an absence of local guidance as to: 1. The circumstances in which GPs can safely oversee the prescription of multiple analgesics at high doses in the community, attempting to reduce reliance on such medication as indicated; and 2. When referral to a pain specialist is mandated. 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you and 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 17th January 2022. 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 on behalf of Ms Jeffries's family. I have also sent a copy to Dr who may find it useful or of interest. , General Practitioner, I am also under a duty to send the Chief Coroner a copy of your response. The Chief Coroner mav publish either or both in a complete or redacted 2 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: 22nd November 2021 Signature: Christopher ·s HM Area Coroner, Man1Cf'lf!ll!Stlw South - 3
2 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.
Gr e at er M a n c h e st er H e alt h a n d S o ci al C ar e P art n er s hi p 4t h Fl o or 3 Pi c c a dill y Pl a c e L o n d o n R o a d M a n c h e st er M 1 3 B N D a t e: 1 7 J a n u ar y 2 0 2 2 Mr C M orri s H M S e ni or C or o n er C o r o n er’ s C o urt 1 M o u nt T a b or Str e et St o c k p ort S K 1 3 A G D e ar Mr M orri s R e: R e g ul ati o n 2 8 R e p ort t o Pr e v e nt F ut ur e D e at h s – Mi c h ell e J effri e s 2 7/ 0 3/ 2 1 T h a n k y o u f or y o ur R e g ul ati o n 2 8 R e p ort d at e d 2 2/ 1 1/ 2 1 c o n c er ni n g t h e s a d d e at h of Mi c h ell e J effri e s o n 2 7/ 0 3/ 2 1 . Fir stl y, I w o ul d li k e t o e x pr e s s m y d e e p c o n d ol e n c e s t o Mi c h ell e J effri e s’ f a mil y. T h e i n q u e st c o n cl u d e d t h at Mi c h ell e’ s d e at h w a s a r e s ult of t h e c o m bi n e d t o xi c eff e ct s of p ai n m e di c ati o n s . F oll o wi n g t h e i n q u e st y o u r ai s e d c o n c er n s i n y o ur R e g ul ati o n 2 8 R e p ort t o Gr e at er M a n c h e st er H e alt h a n d S o ci al C ar e P art n er s hi p ( G M H S C P) t h at t h er e i s a ri s k f ut ur e d e at h s will o c c ur u nl e s s a cti o n i s t a k e n. T hi s l ett er a d dr e s s e s t h e i s s u e s t h at f all wit hi n t h e r e mit of G M H S C P a n d h o w w e c a n s h ar e t h e l e ar ni n g fr o m t hi s c a s e . P oi nt 1 – t h e cir c u m st a n c e s i n w hi c h G P’ s c a n s af el y o v er s e e t h e pr e s cri pti o n of m ulti pl e a n al e g e si c s i n hi g h d o s e s i n t h e c o m m u nit y, att e m pti n g t o r e d u c e r eli a n c e o n s u c h m e di c ati o n s a s i n di c at e d . T h e Tr aff or d C C G M e di ci n e s O pti mi s ati o n t e a m s u p p ort pr e s cri b er s wit h m a n y a s p e ct s of pr e s cri bi n g i n cl u di n g r e p e at pr e s cri bi n g t o e n s ur e r o b u st a n d s af e pr o c e s s e s f or m a n a gi n g p ati e nt s r e p e at m e di c ati o n ar e i n pl a c e. I n cl u d e d a s p art of t hi s ar e s y st e m s f or r e vi e wi n g p ati e nt s o n “ hi g h ri sk ” m e di c ati o n, w hi c h s u p p ort s pr e s cri b er s t o e n s ur e t h at p ati e nt s o n t h e s e m e di ci n e s h a v e r e g ul ar m e di c ati o n r e vi e w s, i n cl u di n g bl o o d a n d p h y si c al h e alt h c ar e m o nit ori n g. All pr a cti c e s i n Tr aff or d n o w h a v e a pr a cti c e b a s e d p h ar m a ci st w or ki n g wit h t h e m a n d a s p art of t h eir w or k t h e y u n d ert a k e str u ct ur e d m e di c ati o n r e vi e w s. I n a d diti o n, t h e C C G M e di ci n e s O pti mi s ati o n t e a m h a v e r e c e ntl y hi g hli g ht e d t o pr a cti c e s t h at pr e s cri bi n g of a n al g e si a i s a n ar e a w e c o ul d w or k c oll a b or ati v el y o n t o e n s ur e t h at p ati e nt s g et t h e b e st o ut c o m e s fr o m t h eir tr e at m e nt. P art of t hi s w o ul d b e t o u n d ert a k e a str u ct ur e d m e di c ati o n r e vi e w wit h t h e p ati e nt, di s c u s si n g t h eir c urr e nt tre at m e nt a n d t h e o ut c o m e s fr o m t h e m. Wit h t h e p ati e nt s a gr e e m e nt a n y tr e at m e nt s t h at t h e p ati e nt w a s n’t be n efitti n g fr o m w o ul d b e r e m o v e d fr o m t h eir m e di c ati o n. D e p e n di n g o n t h e t y p e of m e di c ati o n, t hi s m a y b e d o n e i m m e di at el y or o v er a p er i o d of ti m e, t o e n s ur e a d v er s e si d e eff e ct s of wit h dr a w al fr o m t h e m e di c ati o n di d n ot h a p p e n. R e d u ci n g o v er pr e s cri bi n g, i n cl u di n g a n al g e si a i s p art of t h e D e p art m e nt of H e alt h a n d S o ci al C ar e ( D H S C) g ui d a n c e; G o o d F or Y o u, G o o d F or U s, G o o d f or E v er y b o d y - A pl a n t o r e d u c e o v er p r e s cri bi n g t o m a k e p ati e nt c ar e b ett er a n d s af er, s u p p ort t h e N H S, a n d r e d u c e c ar b o n e mi s si o n s . P ai n m a n a g e m e nt a n d NI C E g ui d a n c e h a v e pr e vi o u sl y b e e n di s c u s s e d at Tr aff or d l o c al G P E d u c ati o n s e s si o n s, h el d q u art erl y. Pl e a s e s e e d o c u m e nt s att a c h e d b el o w f or f urt h er i nf or m ati o n o n t h e Tr aff or d C C G l o c al g ui d a n c e o n R e p e at Pr e s cri bi n g a s w ell t h e N ati o n al I n stit ut e f or Cli ni c al E x c ell e n c e ( NI C E) g ui d a n c e i n r el ati o n t o a s s e s si n g a n d m a n a gi n g c hr o ni c p ai n i n t h e o v er 1 6’ s. T h e R e p e at Pr e s cri bi n g g ui d a n c e i s c urr e ntl y u n d er r e vi e w a n d will b e c o m pl et e b y 3 1 st M ar c h 2 0 2 2 . T C C G _ R e p e at_ Pr e s cri bi n g_ G ui d a n c e_ FI N A L c hr o ni c- p ai n- pri m ar y - a n d-s e c o n d ar y -i n- o v P oi nt 2 - w h e n r ef err al t o a p ai n s p e ci a li st is m a n d at e d . I n t er m s of w h e n t o r ef er p ati e nt s t o p ai n s p e ci ali st s, t h er e i s n o s p e cifi c p ai n m a n a g e m e nt p at h w a y t h at off er s G P s g ui d a n c e o n w h e n e x a ctl y t o r ef er t o a p ai n s p e ci ali st. H o w e v er, i n Tr aff or d, t h er e i s a c o m mi s si o n e d M u s c ul o s k el et al ( M S K) s e r vi c e a v ail a bl e t o p ati e nt s a s w ell a s t h e M a n c h e st er P ai n S er vi c e s h o ul d a n y Tr aff or d G P, b a s e d o n t h eir o w n cli ni c al j u d g e m e nt, d e ci d e a r ef err al i s n e c e s s ar y. T h e c ult ur e i n p ai n m a n a g e m e nt i s c h a n gi n g wit h p ati e nt s b ei n g off er e d n o n - p h ar m a c ol o gi c al h el p a n d s u p p ort, i n pr ef er e n c e, t o m a n a g e t h eir l o n g t er m c o n diti o n r at h er t h a n m e di ci n e s t o tr y t o “ kill t h e p ai n”. T hi s r e p ort gi v e s c oll e a g u e s a t a n gi bl e e x a m pl e t o u s e i n r e mi n di n g al l G P s i n Gr e at er M a n c h e st er a b o ut t h o s e ri s k s, w h at cli ni ci a n s s h o ul d b e c o n si d eri n g i n t er m s of g ui d a n c e a n d t h e r e s o ur c e s a v ail a bl e t o s u p p ort cli ni ci a n s i n t h e m a n a g e m e nt of p ati e nt s wit h c hr o ni c p ai n. A cti o n s t a k e n or b ei n g t a k e n t o pr e v e nt r e o c c urr e n c e a cr o s s Gr e at er M a n c h e st er. 1. L e ar ni n g t o b e pr e s e nt e d/ s h ar e d wit h t h e Gr e at er M a n c h e st er Q u alit y B o ar d. T hi s m e eti n g i s att e n d e d b y c o m mi s si o n er s, i n cl u di n g c o m mi s si o n er s of s p e ci ali st s er vi c e s, r e g ul at or s, H e alt h w at c h a n d NI C E . 2. C o m m u ni c ati o n t o all pr o vi d er s t o s h ar e a p pr o pri at e a d vi c e a n d g ui d a n c e a n d i ncr e a s e st aff a w ar e n e s s r e g ar di n g t h e r a n g e of m at eri al s t h at ar e alr e a d y a v ail a bl e. 3. S h ar e d l e ar ni n g fr o m t hi s a n d si mil ar c a s e s at Gr eat er M a n c h e st er a n d b or o u g h l e v el will b e c a s c a d e d t o pr of e s si o n al s t hr o u g h a p pr o pri at e g o v er n a n c e a n d l e ar ni n g f or u m s . 4. C C G s a cr o s s G r e at er M a n c h e st er will b e a s k e d t o pr o vi d e t hr o u g h Q u alit y B o ar d, a r e p ort o n h o w t h e y ar e re d u ci n g o v er pr e s cri bi n g, i n cl u di n g a n al g e si a a n d s u p p ort t h e i m pl e m e nt ati o n of “ D e p art m e nt of H e alt h a n d S o ci al C ar e ( D H S C) g ui d a n c e; G o o d F or Y o u, G o o d F or U s, G o o d f or E v er y b o d y - A pl a n to r e d u c e o v er pr e s cri bi n g t o m a k e p ati e nt c ar e b ett er a n d s af er, s u p p ort t h e N H S, a n d r e d u c e c ar b o n e mi s si o n s. ” I n c o n cl u si o n, k e y l e ar ni n g p oi nt s a n d re c o m m e n d ati o n s will b e m o nit or e d t o e n s ur e t h e y ar e e m b e d d e d wit hi n pr a cti c e. G M H S C P i s c o m mitt e d t o i m pr o vi n g o ut c o m e s f or t h e p o p ul ati o n of Gr e at er M a n c h e st er. I h o p e t hi s r e s p o n s e pr o vi d e s t h e r el e v a nt a s s ur a n c e s y o u r e q uir e. T h a n k y o u f or bri n gi n g t h e s e i m p ort a nt p ati e nt s af et y i s s u e s t o m y att e nti o n a n d pl e a s e d o n ot h e sit at e t o c o nt a ct m e s h o ul d y o u n e e d a n y f urt h er i nf or m ati o n. Y o ur s s i n c er el y C h ai r of G M M e di c al E x e c uti v e, G M H S C P
Private & Confidential
F.A.O: Christopher Morris
HM Area Coroner for Manchester South
HM Coroner’s Office
The Coroner’s Court
Mount Tabor Street
Stockport
SK1 3AG
Dear Mr Morris
Re: Ms Michelle Jeffries
1st Floor
Trafford Town Hall
Talbot Road
Stretford
Manchester M32 0TH
Tel: 0161 912 4093
E-mail:
16th December 2021
I write in response to the Regulation 28: Prevention of Future Death notice dated 22nd
November 2021 and respond accordingly to the matters raised in relation to the death
of the late Ms Michelle Jeffries. Firstly, on behalf of Trafford Clinical Commissioning
Group (CCG), I would like to offer Ms Jeffries family our sincerest condolences and
we hope this response helps to answer any questions that remain outstanding for
them.
You specifically asked us as a CCG to respond to section 5: Matters of Concern, and
we would like to offer the following information which we hope is helpful.
1.
The circumstances in which GP’s can safely oversee the prescription of
multiple analgesics at high doses in the community, attempting to reduce
reliance on such medication as indicated and;
2. When a referral to a pain specialist is mandated.
The CCG Medicines Optimisation team support prescribers with many aspects of
prescribing including repeat prescribing to ensure robust and safe processes for
managing patients repeat medication are in place. Included as part of this are systems
for reviewing patients on “high risk” medication, which supports prescribers to ensure
that patients on these medicines have regular medication reviews, including blood and
physical healthcare monitoring.
In addition, the CCG Medicines Optimisation team have recently highlighted to
practices that prescribing of analgesia is an area we could work collaboratively on to
ensure that patients get the best outcomes from their treatment. Part of this would be
to undertake a structured medication review with the patient, discussing their current
treatment and the outcomes from them. With the patients agreement any treatments
that the patient wasn’t benefitting from would be removed from their medication.
1
Depending on the type of medication, this may be done immediately or over a period
of time, to ensure withdrawal from the medication did not happen.
Reducing overprescribing, including analgesia is part of the Department of Health and
Social Care (DHSC) guidance; Good For You, Good For Us, Good for Everybody - A
plan to reduce overprescribing to make patient care better and safer, support the NHS,
and reduce carbon emissions.
All practices in Trafford now have a practice based pharmacist working with them and
as part of their work they undertake structured medication reviews. The CCG
Medicines Optimisation Team and practice based teams have been working together
to prioritise patients requiring a medication review, with patients on high doses or
multiple analgesia being highlighted.
Pain management and NICE guidance have previously been a topic at our local GP
Education sessions, held quarterly. Please see documents attached below for further
information on the Trafford CCG local guidance on Repeat Prescribing as well the
National Institute for Clinical Excellence (NICE) guidance in relation to assessing and
managing chronic pain in the over 16’s. The Repeat Prescribing guidance is currently
under review and will be complete by 31st March 2022.
TCCG_Repeat_Prescri
bing_Guidance_FINAL
chronic-pain-primary
-and-secondary-in-ov
In terms of when to refer patients to pain specialists, there isn’t a specific pain
management pathway that offers GP’s guidance on when exactly to refer to a pain
specialist. However, in Trafford, there is a commissioned Musculoskeletal (MSK)
service available to patients as well as the Manchester Pain Service should any
Trafford GP, based on their own clinical judgement, decide a referral is necessary.
• Trafford Community Musculoskeletal (MSK) Service.
The MSK service provides treatments for adults (over 18) with Musculoskeletal
(muscles, joints and bones) and orthopaedic conditions or injuries as well as
chronic pain. The service offers multi-disciplinary care for patients experiencing
persistent pain and mild to moderate distress. This involves Biopsychosocial
assessment,
treatment, Pain Management Programmes and
medication advice. The team includes Clinical and Health Psychologists,
Specialist Physiotherapists and Specialist Pain Nurses.
individual
2
• The Manchester Pain Service
This is an integrated multidisciplinary pain service spanning the spectrum of
acute and chronic pain. As well as helping to optimise pain relief during inpatient
stays following surgical procedures or trauma, they also offer an outpatient
service for pain which is more persistent or ‘chronic pain’. This is managed by
a team of doctors, nurses, physiotherapists and psychologists and as a
multidisciplinary team they aim to ease or reduce pain where possible, as well
as offer support and guidance to help improve a patient’s quality of life.
This extremely sad case has highlighted a number of risks that can occur in healthcare
where potent and high risk medicines are prescribed.
Fortunately the culture in pain management is changing with patients being offered
non-pharmacological help and support, in preference, to manage their long term
condition rather than medicines to try to “kill the pain”. This report gives us a real
example to use in reminding all GPs in Trafford about those risks, what clinicians
should be considering in terms of guidance and the resources available to support
clinicians in the management of patients with chronic pain. We have therefore included
this in our “Practice Briefing”; an email update which is sent out to over 400 Primary
Care staff in Trafford twice a week. The information in the briefing also includes a link
to the guidance documents we have shared with you above.
By way of further assurance, I am pleased to say that we currently have 27 practices
in Trafford, 25 of those are rated as “Good” with the Care Quality Commission (CQC)
and 2 are rated as “Outstanding”. The CQC process of monitoring and inspecting GP
practices covers areas of medicines management which include, prescribing of
controlled drugs, medication reviews and systems for monitoring high risk medicines.
We don’t have any practices with any outstanding action plans or regulatory notices
with CQC at this time, and all of our practices are subject to the current routine CQC
monitoring process in place. Our Quality Team meet regularly with our local CQC
Inspector to discuss any areas of concern and where we can support our practices
maintain high quality services. We also have an internal Quality Assurance Framework
where we use data and soft intelligence to enable us to monitor elements of quality
with our practices on a regular basis.
We hope our response is satisfactory for the issues raised, please do not hesitate to
contact us should you require further clarification
Medical Director
3
See every Prevention of Future Deaths report matching Alcohol, drug and medication related deaths, 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.