Prevention of Future Deaths reports · 2022
Regulation 28 report to prevent future deaths, reference 2022-0380, written 26 Sep 2022. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 26 Sep 2022 |
|---|---|
| Reference | 2022-0380 |
| Deceased | Lewis Begley |
| Coroner | Jacqueline Lake |
| Coroner area | Norfolk |
| Category | Alcohol, drug and medication related deaths |
| Organisation named | Norfolk and Suffolk NHS Foundation Trust |
| 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 NOTE: This form is to be used after an inquest. REGULATION 28 REPORT TO PREVENT DEATHS THIS REPORT IS BEING SENT TO: Chief Executive Norfolk and Suffolk NHS Foundation Trust Hellesdon Hospital Drayton High Road Norwich NR6 5BE 1 CORONER I am Jacqueline LakeJacqueline LAKE, Senior Coroner for the Coroner Area of Norfolk 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 29 December 2020 I commenced an investigation into the death of Lewis Robert BEGLEY aged 35. The investigation concluded at the end of the inquest on 13 September 2022. The medical cause of death was: Central Nervous System and Respiratory Depression Combined Drug Toxicity 1a) 1b) 1c) 2) The conclusion of the inquest was: Misadventure and Neglect contributed to the cause of death. 4 CIRCUMSTANCES OF THE DEATH Mr Begley was placed on Section 2 of the Mental Health Act and admitted to Samphire Ward, Chatterton House on 12 December 2020. He was placed on 4 times per hour observations when in communal areas and general hourly observations when he was in his bedroom. Mr Begley was seen to be acting in a suspicious manner during the early hours of 15th December 2020 whilst in the communal area. On 15th December 2020, Mr Begley gained access to the medicine room between 02.29.04 and 02.29.23 and again between 02.31.10 and 02.45.51. Upon being found in the medicine room, there was a failure to escalate risk to relevant persons. In addition, consideration was not given to further safeguarding checks in ensuring Mr Begley's safety. Multiple policies and practices were not followed adequately including the: Therapeutic Observations Policy, Searching Policy, Management of Medicines Policy. Inaccurate and inadequate information was handed over to other members of staff on shift and coming on shift. On the morning of the 15th December 2020, Mr Begley was found unresponsive in his room. CPR was commenced by staff. Emergency Services attended and Mr Begley was pronounced dead at the scene. At post mortem, a split plastic bag, containing 2 in addition to other tablets of shape, colour and size which were unidentifiable, were found in Mr Begley's rectum. 5 CORONER’S CONCERNS Regulation 28 – After Inquest Document Template Updated 30/07/2021 During the course of the investigation my inquiries 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. Evidence was heard that medication is kept in a locked room and in locked cabinets, in accordance with legislation. However, there is no record kept as to what medication is stored and how much, particularly which is a drug subject to misuse, in a mental health hospital where many patients have a history of drug misuse and suicidal ideation and actively seek out the drugs cupboard. 2. On a patient accessing medication, there is no knowledge as to whether anything has been taken and if so, how much, thereby limiting knowledge as to what treatment is to be considered and what action to be taken 3. Evidence was heard that there is no fixed training given to doctors with regard to the administering of drugs overdose. in the event of there being a suspected 6 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. 7 YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by November 21, 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 to the following Interested Persons Mr and Mrs Begley, parents And sister I have also sent it to Care Quality Commission (CQC) Department of Health HSIB Healthwatch Norfolk NHS ENGLAND (NHS IMPROVEMENT) NSFT Legal Services who may find it useful or of interest. 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 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 Regulation 28 – After Inquest Document Template Updated 30/07/2021 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: 26/09/2022 Jacqueline LAKE Senior Coroner for Norfolk County Hall Martineau Lane Norwich NR1 2DH Regulation 28 – After Inquest Document Template Updated 30/07/2021
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.
Ms Jacqueline Lake Norfolk Coroner’s Service County Hall Martineau Lane Norwich NR1 2DH Dear Ms Lake Trust Management Main Administration Block Hellesdon Hospital Drayton High Road Norwich NR6 5BE 17th November 2022 Regulations 28 and 29 (2013) notification made in response to the death of Lewis Begley. I write to you in respect of Lewis Begley who died in December 2020. His inquest was held in September 2022, at the end of the inquest you raised concerns outlined in this response within a prevention of future deaths notification. I would like to reiterate to you and importantly to Lewis’s family our sincere regret and apologies for the death of Lewis whilst under our care. The concerns you raised are outlined below with our trust response to each point: 1. Evidence was heard that medication is kept in a locked room and in locked cabinets, in accordance with legislation. However, there is no record kept as to what medication is stored and how much, particularly which is a drug subject to misuse, in a mental health hospital where many patients have a history of drug misuse and suicidal ideation and actively seek out the drugs cupboard. We have recently employed a new Chief Pharmacist in the trust who has already begun improvement work in this area her initial action plan includes: • Medicines Management Policy to be revised, implemented and monitored across the trust. • Safe and Secure Handling of medication audit will now be led by Pharmacy, this is a change in process and accountability and address the issues of stock oversight in ward areas. • Audit action plan will be developed for each clinical area together with nursing and pharmacy team. • Pharmacy to support Medicines Management Efficacy &Treatment at ward level. • All staff complete Medicines Management training as Statutory and Mandatory training. 2. On a patient accessing medication, there is no knowledge as to whether anything has been taken and if so, how much, thereby limiting knowledge as to what treatment is to be considered and what action to be taken As above. 3. Evidence was heard that there is no fixed training given to doctors with regard to the administering of drugs overdose. In line with other mental health trusts, we will continue to train staff and stock as part of the resuscitation response adhering to the Resuscitation Council UK guidelines, both nurses and medics are able to administer this drug to reverse a suspected or known opiate overdose. in the event of there being a suspected l and in line again with other mental health trust we will continue to stock In respect of as a potential antidote to a suspected or known overdose; in case there is a medic available who is experienced and able to administer. However, we will not train our medics to administer this as the skill cannot be maintained without regular use. To note in our internal review the ambulance trust advised that the ambulance crews and paramedics do not administer this drug unless they have a specialist medic on the team for the same reason. Please note the guidance below: should only be administered by, or under the direct supervision of, personnel experienced in its BNF “ use. can be hazardous, particularly in mixed overdoses Use of the involving may prevent the need for ventilation, particularly in patients with severe respiratory disorders; it should be used on expert advice only and not as a diagnostic test in patients with a reduced level of consciousness.” antidepressants or in -dependent patients. can be hazardous because of risks of precipitating seizures and ventricular arrythmias. It should Maudsley Practice Guidelines for Physical Heath Conditions in Psychiatry by David Taylor et al “ only be used by people with previous experience of its use (or in the presence of people with experience).” “In the UK it is only licensed for reversal of sedative effects of procedures, or in intensive care. The main focus of managing suspected be to resuscitate according to ABCDE approach and transfer care to emergency services.” in anaesthesia, other clinical overdose should I hope that this response answers your concerns, the sad death of Lewis was not anticipated however we apologise that we did not have the robust systems in place at that time which would have enabled staff to ascertain what and how much medication he had acquired. It is anticipated that in light of the Chief Pharmacists improvement plan our medication management systems will meet the necessary safety levels in the future providing confidence and resilience for all. Yours sincerely Chief Executive Officer
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