Prevention of Future Deaths reports · 2022
Regulation 28 report to prevent future deaths, reference 2022-0395, written 8 Dec 2022. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 8 Dec 2022 |
|---|---|
| Reference | 2022-0395 |
| Deceased | Tracy Brown |
| Coroner | Robert Simpson |
| Coroner area | Hampshire, Portsmouth and Southampton |
| 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.
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: 1 2 3 Chief Coroner - PFD Reports 1 CORONER I am Robert SIMPSON, Assistant Coroner for the coroner area of Hampshire, Portsmouth and Southampton 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 11 January 2022 I commenced an investigation into the death of Tracy Marie BROWN aged 52. The investigation concluded at the end of the inquest on 06 December 2022. The conclusion of the inquest was that: On the 5th January 2022 Tracy Marie Brown died at her home address in Withington Close, Portsmouth after taking an excessive quantity of some of her prescribed medication. She had a history of psychosis and her mental health had deteriorated over the past month. 4 CIRCUMSTANCES OF THE DEATH Drug related 5 CORONER’S CONCERNS 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: (brief summary of matters of concern) I heard evidence that medication for Ms Brown was required to be kept in a locked box due to a risk of her not taking the correct amount or taking too much medication. This was since Apex Care became involved in her care in March 2021. Despite this identified risk staff left regularly a nomad box containing a week's worth of medication unsecured in her kitchen cupboard. On the digital application used to inform carers of what medication to administer, which was used by the carers daily, there was no reference to keeping the medication in the secure box. 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. Regulation 28 – After Inquest Document Template Updated 30/07/2021 7 YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by February 02, 2023. 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 I have also sent it to 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 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: 08/12/2022 Robert SIMPSON Assistant Coroner for Hampshire, Portsmouth and Southampton 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.
14 Bartram Road
Tatton
Southampton
Hampshire
SO409JG
APEX
Helping people remain
in control of their lives
David Gregory OBE QPM
Coroner's Officer, Portsmouth Office
Hampshire, Portsmouth, and Southampton Coroners Service
The Coroner's Court
1 Guildhall Square
Portsmouth
P01 2GJ
Regulation 28 report to prevent future deaths
Tracy Marie Brown
Inquest O6 December 2022
Following on from the recommendations from the coroner's report there were recommendations
with reference to the medication and how it was stored.
When TB moved into Bresler house in March 2021 we were commissioned to provide a package of
care for TB. The senior carer went and completed the initial assessment which included setting
out a care plan and completing the risk assessments.
30mins (AM before 12pm) 7 days a week to help with prompting personal care, supporting
•
with preparing food and drink, supporting to prompt medication, to help with social
isolation.
4:30pm 15mins 7 days a week to help with prompting personal care, supporting with
•
preparing meal and drink, supporting to prompt medication, to help with social
isolation.
08:30pm 15mins 7 days a week to help with prompting personal care, supporting with
•
preparing food and drink, supporting to prompt medication, to help with social
isolation.
laundry and
1hr per week additionally to support with maintaining home conditions,
•
changing the bedding.
The assessments were completed, and the care plan written up.
The sheltered housing scheme manager was happy to support in prompting Tracey to take her
medication the medication was in a nomad which was delivered to the Bresler house office, and
the staff would keep it until TB was ready for it. This would cause us problems as when we needed
to get a new nomad the staff weren't always available, and the office locked, so if there was just
one lot of medication left, we would go to the office to collect new nomad and place in the locked
tin. The tin was small and only had room for one nomad at a time.
Apex Prime Care Ltd
Registered Office Windsor House, Bayshill Road, Cheltenham GLS0 3AT
Registered Number 4296566
Page 1 of 2
On some occasions TB would be out when we were commissioned to go in to carry out the care so
we would inform Bresler staff, and they would then help TB to take her medication.
Since the passing of TB Apex Prime Care have learnt valuable lessons with reference to
medication, we quickly reassessed every service user that has medication in a locked box to store
medication. There now must be room to place all medication in the locked box with no other
medication stored in the property. Some service users have had to purchase 2 locked boxes to fit
all the medication in or a safe.
reiterate to the service user or their families not to buy over the counter medication as we are
unable to monitor this closely and are unaware of what the service user is taking.
If the delivery is weekly only, when we do the assessment, we
There is a task on the care plan of how medication is to be given and where it is stored but, on this
occasion, it wasn't which I should have picked up when I audited the care plan before going into
I have learnt a valuable lesson and I have filtered this down to all my
the service user's property.
office staff and no care plans go out without this task in place.
Apex Prime Care has also changed their medication policy to reflect medication and locked boxes
{I have included the new updated policy and highlighted in yellow the changes to the policy).
Yours faithfully
Managing Director
Page 2 of 2
Apex Prime Care Ltd
Registered Office Windsor House, Bayshill Road, Cheltenham GL50 3AT
Registered Number 4296566
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