Prevention of Future Deaths reports · 2022
Regulation 28 report to prevent future deaths, reference 2022-0382, written 28 Nov 2022. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 28 Nov 2022 |
|---|---|
| Reference | 2022-0382 |
| Deceased | Susan Perry |
| Coroner | Graeme Hughes |
| Coroner area | South Wales Central |
| Category | Alcohol, drug and medication related deaths · Wales prevention of future deaths reports (2019 onwards) |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
GRAEME HUGHES
HIS MAJESTY’S
SENIOR CORONER
SOUTH WALES CENTRAL
CORONER AREA
CORONER’S OFFICE
THE OLD COURTHOUSE
COURTHOUSE STREET
PONTYPRIDD
CF37 1JW
ANNEX A
REGULATION 28: REPORT TO PREVENT FUTURE DEATHS (1)
NOTE: This form is to be used after an inquest.
REGULATION 28 REPORT TO PREVENT FUTURE DEATHS
THIS REPORT IS BEING SENT TO:
The Chief Executive, MIRUS Wales
CORONER
1
2
I am Graeme Hughes Senior Coroner, for the coroner area of South Wales Central.
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.
INVESTIGATION and INQUEST
On 2 November 2020 I commenced an investigation into the death of Susan Jane PERRY .
The investigation concluded at the end of the inquest on 24.11.22 . The conclusion of the inquest was:-
3
The deceased died due to the indivisible contribution of COVID-19 infection and elevated levels of her
prescription medication. In combination, these have likely led to central nervous system depression and her
death.
Her Cause of Death was found to be: -
1a Mixed (Prescription) Drug Toxicity with Covid 19 Infection
1b
1c
II
CIRCUMSTANCES OF THE DEATH
These were recorded as :-
Susan Parry had a chronic complex mental ill health condition. In order to manage the same, she had
required long-term care and support.
At the time of her death, she was receiving the same at 21 Rockwood Avenue Llandaff.
From around the 17th of October 2020, both her mental and physical health deteriorated. Posthumously,
she was found to be infected with the COVID-19 virus.
To manage her mental ill health, she was prescribed a range of medication which was slightly altered on the
20th of October 2020. During the week, she became more lethargic, remaining in her room. On the morning
of the 23rd of October 2020, she was found deceased there by her support workers.
4
Post-mortem examination, supported by toxicological analysis found that she had died due to a
combination of mixed prescribed drug toxicity and COVID-19 infection.
The Inquest focused upon: -
a. How she came to have such elevated levels of her prescription medication in her post-mortem
blood samples and the contribution that may have had to her death. Whilst the precise causation of
the same was not established on the evidence, it was found that neither she, nor her support
workers had administered an overdose(s) of her medication deliberately, or accidentally. It was
found, on a balance of probabilities, that the elevated levels were more likely to have their
causation in post-mortem re-distribution and/or the instability of the medication for the purposes
of toxicological testing.
.
CORONER’S CONCERNS
During 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.
5
(1) I received evidence from her support workers that service user's medications were kept in locked
cupboards on the ground floor. However, the keys to the same were kept either in an unlocked drawer
nearby, or in a pot on an adjacent, or nearby work surface. I sought clarification upon this and evidence to
determine if this arrangement was still in place today. Whilst I did not receive any evidence per se on this
matter, the indication I received from counsel for MIRUS Wales did not satisfy me, that arrangements for
access to this cupboard had been altered or revised since Susan Perry’s death on 23.10.20.
(2) My concern is simply that these arrangements give rise to a risk that a service user could access
medication (their own, or other service users) from the locked cupboards by opening the same using the
nearby keys, defeating the purpose of securing the medication. Deliberate, or inadvertent administration of
such medication could well lead to the death of that individual.
(3) I believe that MIRUS Wales operate several similar supported accommodation concerns across South
Wales, and I received no evidence to satisfy me that practices & procedures were in place across these
concerns to address this risk of self-harm.
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.
YOUR RESPONSE
You are under a duty to respond to this report within 56 days of the date of this report, namely by 23rd
January 2023 unless 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.
6
7
COPIES and PUBLICATION
I have sent a copy of my report to family who may find it useful or of interest.
Also to Care inspectorate Wales & Welsh Government.
8
I am also 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.
28 November 2022
9
SIGNED:
Graeme Hughes Senior Coroner for South Wales Central Coroner Area
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.
Strictly Private and Confidential Mr Graeme Hughes HM Senior Coroner The Old Courthouse Courthouse Street Pontypridd CF37 1JW 3rd January 2023 Dear Graeme Hughes (HM Senior Coroner) Re: Prevention of Future Death report following inquest into the death of Susan Jane Perry. Further to your letter dated 29th November 2022 concerning the Regulation 28 Report to prevent Future Deaths and your requirement for me to respond to your concerns in relation to: (1) I received evidence from her support workers that service user's medications were kept in locked cupboards on the ground floor. However, the keys to the same were kept either in an unlocked drawer nearby, or in a pot on an adjacent, or nearby work surface. I sought clarification upon this and evidence to determine if this arrangement was still in place today. Whilst I did not receive any evidence per se on this matter, the indication I received from counsel for MIRUS Wales did not satisfy me, that arrangements for access to this cupboard had been altered or revised since Susan Perry’s death on 23.10.20. (2) My concern is simply that these arrangements give rise to a risk that a service user could access medication (their own, or other service users) from the locked cupboards by opening the same using nearby keys, defeating the purpose of securing the medication. Deliberate, or inadvertent administration of such medication could well lead to the death of that individual. (3) I believe that MIRUS Wales operate several similar supported accommodation concerns across South Wales, and I received no evidence to satisfy me that practices & procedures were in place across these concerns to address this risk of self-harm. Actions taken to prevent further incidents from occurring mirus possibilities into realities Registered Address: mirus Wales, Unit 5, Cleeve House, Lambourne Crescent, Llanishen, Cardiff. CF14 5GP Tel: 029 20236216, Email: admin@mirus-wales.org.uk , Website: www.mirus-wales.org.uk Registered Charity • mirus has reviewed its medication policy, procedures, and practice in relation to the handling of keys. (Action completed 5th December 2022) Within the policy we have reworded the expectations of ‘key holders’ "Where the requirement is for medication to be in locked storage, as identified by the Medication risk assessment; arrangements must be in place for keys to be kept on the nominated medication key holder's person at all times". We have instructed managers to conduct an observation of practice to all • staff who have responsibility to administer medication by the end of December 2022. • The content of the medication training for staff and managers has been updated to strengthen the additional measures for handling of keys to ensure safe storage and prevent unauthorised access to medication. (Action taken 5th December 2022) • Additional quality assurance measures will follow to ensure that the above actions have been implemented. (Action by end of February 2023) The above measures will be subject to full scrutiny at our leadership meetings and at the next full Board of Trustee meeting in March 2023. The incident was previously reported to the Charity Commission, and we have since provided them with a further update and shared your findings with them. Trustees have been fully briefed on the incident and the outcome of the coroner's inquest on 12th December 2022 a full Board of Trustee meeting. We have notified Care Inspectorate Wales (CIW) at the time of Susan Jane Perry’s death and have provided updates of the incident and the outcome of the inquest to them. (See attached serious incident form and updates). In addition to this, we have notified Cardiff Social Services commissioning authority of the incident and the outcome of the inquest. (See attached serious incident form and updates). Should you require any further evidence of the actions taken please let me know as soon as possible. Yours sincerely Chief Executive Officer mirus possibilities into realities Registered Address: mirus Wales, Unit 5, Cleeve House, Lambourne Crescent, Llanishen, Cardiff. CF14 5GP Tel: 029 20236216, Email: admin@mirus-wales.org.uk , Website: www.mirus-wales.org.uk Registered Charity
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