Prevention of Future Deaths reports · 2022
Regulation 28 report to prevent future deaths, reference 2022-0227, written 25 Jul 2022. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 25 Jul 2022 |
|---|---|
| Reference | 2022-0227 |
| Deceased | Natalie Mortimer |
| Coroner | Bina Patel |
| Coroner area | Mid Kent and Medway |
| Category | 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.
Mid Kent and Medway Coroners Cantium House 2nd Floor Maidstone Kent ME14 1XD REGULATION 28 REPORT TO PREVENT FUTURE DEATHS Natalie Mortimer (died 21.04.2022) THIS REPORT IS BEING SENT TO: GP Partner at Green Porch Medical Centre Green Porch Medical Centre 1. CORONER I am Bina Patel, Area Coroner for the coroner area of Mid Kent & Medway. 2. CORONER’S LEGAL POWERS I make this report under the Coroners and Justice Act 2009, paragraph 7, Schedule 5, and The Coroners (Investigations) Regulations 2013, regulations 28 and 29. 3. INVESTIGATION and INQUEST On 3rd May 2022 I commenced an investigation into the death of Natalie Mortimer who died, aged 27, on 21st April 2022 at St Thomas’ Hospital, Lambeth Palace Road, London. The investigation concluded at the end of an inquest on 14th July 2022, conducted by me. I gave a narrative conclusion that: Natalie Mortimer died on the 21st April 2022 at St Thomas' Hospital, Lambeth Palace Road, London. She was transferred to the intensive team at St Thomas' Hospital from Medway Maritime Hospital after presenting there on the 16th April 2022 with abdominal pain, diarrhoea and vomiting following an overdose of tablets on the 15th April 2022 prescribed to her for gout. She died from multiorgan failure caused by colchicine overdose. She had a previous overdose attempt in April 2021 prior to her death and a past medical history of anxiety and depression. The medical cause of death was: Ia. Multiorgan Failure Ib. Colchicine Overdose 1c II. 4. CIRCUMSTANCES OF THE DEATH Natalie Mortimer died on the 21st April 2022 at St Thomas' Hospital, Lambeth Palace Road, London. She was transferred to the intensive team at St Thomas' Hospital from Medway Maritime Hospital after presenting there on the 16th April 2022 with abdominal pain, diarrhoea and vomiting following an overdose of colchicine tablets on the 15th April 2022 prescribed to her for gout. She died from multiorgan failure caused by colchicine overdose. She had a previous overdose attempt in April 2021 and a past medical history which included anxiety and depression. 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: Evidence was heard that: (1) The GP Practice received a discharge note from the hospital for a previous overdose attempt in April 2021. The patient’s medical record was not updated to reflect this information. (2) On the 25th November 2021 the patient attended the GP Practice and the GP on duty reviewed her most recent consultation which took place on the 22nd November 2021 and her records and prescribed the patient with to be taken 2-4 times a day until symptoms resolve for her gout. The GP detailed in evidence that she issued 100 tablets as this was the default quantity that came up on EMIS. The prescribing doctor stated that there were no alerts or coding of a previous overdose in the patients records which may have been a contraindication for issuing a prescription of 100 tablets and therefore relied on the default quantity generated by the system. 6. ACTION SHOULD BE TAKEN In my opinion, action should be taken to prevent future deaths and I believe that you and/or 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 19th September 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 following: • HHJ Thomas Teague QC, the Chief Coroner of England & Wales • (Father) on behalf of the family of Natalie Mortimer I am 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. Signature: Bina Patel, Area Coroner, Mid Kent & Medway 25th July 2022
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.
Bina Patel
Area
Coroner
Mid Kent and Medway
Coroners Cantium House
2nd Floor
Maidsto
ne Kent
ME14
1XD
RE: Regulation 28 Report to Prevent Future Deaths
Natalie Mortimer (died
21.04.2022)
Dear Mrs. Patel
Thank you for your report dated 25th July 2022.
You have requested a response to this report containing details of action taken to
prevent future deaths.
The above patient died on the 21st April 2022 due to multi-organ failure as a result of
colchicine overdose. This was originally issued in November 2021 for treatment of
gout.
The above patient had a history of depression and anxiety and had an attempted
overdose previously in April 2021. This was not read-coded on the system and no alerts
were in place within the system to highlight this.
We have reviewed this case in depth and have put the following steps in place to ensure
that this does not happen in the future.
1. We have employed a full time read-coder, who will ensure that all letters are
properly read-coded and alerts put on patient records when necessary. The Read-
coder will have the appropriate training to ensure that this is being maintained to
the highest standard. This will ensure that the appropriate letters are sent to the
appropriate member of staff. We plan to deliver refresher training to existing
coders and all new coders to undergo extensive training prior to coding.
2. We have introduced a correspondence triage policy/flow chart – please find
attached – This will ensure that the relevant details are passed on to the most
appropriate member of staff for example a clinician will see all letters regarding
overdoses and suicide attempts in future.
3. We now have a system in place to ensure that relevant important alerts are put on
the system for individual patients. This will initiate as soon as somebody logs into the
records and an alert message will inform the clinician/administration/reception team
what the concerns are. This will be on the screen until it is confirmed as
acknowledged. Alerts will be in place for overdose attempt/Safeguarding
issues/suicidal ideation/domestic violence etc.
4. We have encouraged all clinicians to use the Arden templates for reviewing
depression. Asking the patient about self-harm is incorporated as part of the
template. This will also help to ensure patients safety as it automatically flags up
as a read-code. i.e., history of self-harm/suicidal ideation/Overdose attempt etc.
5. We have had a meeting with the CCG/ICB Medicine Management team regarding
this case, due to the fact that the default prescription for colchicine is for 100
tablets. This has been raised on a local level and has been changed on the system
for local practices. Additionally, they have raised this on a national level via SBAR
(see enclosed) and recommended the following:
• Add quantity limiter to script Switch and limit prescribing to 12 tablets at a time.
• The team would like to communicate this case study to all clinicians in the
Kent and Medway area via the GP bulletin. This is published by NHS
England Primary care. The bulletin is usually sent once a week and is for
teams across general practice, dentistry, community pharmacy and
optometry.
• Remove the quantity of 100 (Pack size) from all EMIS formularies in
GP practices.
• Add warning information message to script Switch regarding the toxicity of
colchicine and be aware of the risk of overdose in the care of patients with a
history of mental health issues.
6. We have put alerts on patient records for anyone requesting colchicine (see
example enclosed) regarding the toxicity to ensure that this is explained to the
patient at their next review. The alert recommends limiting the colchicine to 12
tablets and if there is a history of Mental health, depression, Suicide attempt or
self-harm, to carry out a risk assessment before issuing.
7. We are currently in the process of auditing of Docman to ensure quality
compliance i.e., read-code is appropriate, that the relevant team has seen the document,
any follow ups completed, any concerns raised with the relevant department etc. Audits
will be carried out every 3 months, starting 1st of December 2022.
Thank you for giving us this opportunity to respond. We have learned from this incident
and raised this internally has a significant event, as well as raising this with the CCG/ICB
to disseminate the message more widely in Kent and beyond. Important changes have
been made for the safety of patients in the future as a result of Ms. Mortimer’s death. We
hope that this will be of some small consolation to her family in their loss.
This has been discussed at a clinical meeting to ensure that this does not happen
again in the future.
Yours sincerely
Enclosures
New work flow for incoming correspondence
Screenshot of alert for colchicine
SBAR
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