Prevention of Future Deaths reports · 2023
Regulation 28 report to prevent future deaths, reference 2023-0018, written 19 Jan 2023. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 19 Jan 2023 |
|---|---|
| Reference | 2023-0018 |
| Deceased | Derek Larkin |
| Coroner | Stephen Nicholls |
| Coroner area | Dorset |
| Category | Care Home Health related deaths |
| 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 (1) NOTE: This form is to be used after an inquest. REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: 1. Dorset Council 2. Dorset Clinical Commissioning Group 1 CORONER I am Stephen John Nicholls, Assistant Coroner, for the Coroner Area of Dorset 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 the 31st August 2021, an investigation was commenced into the death of Derek Larkin, born on the 10th January 1964. The investigation concluded at the end of the Inquest on the 12th January 2023 The Medical Cause of Death was: 1a Fatal intoxication with morphine. 2 Chronic Ischaemic heart disease with Stenosing Atherosclerosis of the Coronary arteries The conclusion of the Inquest recorded Accidental death. 4 CIRCUMSTANCES OF THE DEATH Derek Larkin had a known history of misusing his prescription medications. He had been living at home with a care package of support that included live in carers, up until his admission to hospital he had been dealt with by his local GP practice. He was admitted to Royal Bournemouth Hospital, on the 21st January 2021, suffering from Covid and pneumonia, he was successfully treated. 1 On the 8th March 2021 he was discharged from hospital, he was not able to return home and went to reside in a care home. Whilst resident there he was dealt with by a different GP practice. He was prescribed medication. Dorset Council Adult Social Care were responsible for him and had drawn up a Care Plan. Derek Larkin wished to return to his home address and made this known to Adult Social Care in a telephone conversation on the 19th April 2021. Dorset Council liaised with the previous care providers the occupational health team, through a brokerage system they located a different care provider and made arrangements for Derek Larkin to return home on the 20th May 2021. Evidence from healthcare professionals at the inquest confirmed that Derek Larkin had capacity. On the 2nd June 2021 Derek Larkin was found deceased at home by a carer. A post mortem examination demonstrated that he had overdosed on his prescription morphine. From the evidence at the inquest, it is clear that Dorset Council Adult Social Care would have benefited from having knowledge of the medications that had been prescribed. It is clear that family members raised concerns with Adult Social Care about Derek Larkin’s access to medication. In addition Adult Social Care would have benefited from any further information from the current GP practice together with his regular GP practice to enable them to consider what might be included within his care plan to include where the medication might be stored and whether it was to be administered by care staff or whether Derek Larkin was self-administering his medication. 5 CORONER’S CONCERNS The MATTERS OF CONCERN are as follows: There is no evidence that the Dorset Council Adult Social Care computer system Mosaic can communicate with the NHS SytemOne. The Adult Social Care team would benefit from having information about the medication being prescribed to a patient, with the patient’s consent, and when that medication was last reviewed. Dorset Council Adult Social Care would benefit from information held by a current or former GP practice as to a patient’s medication and how to manage any particular concerns raised by health care professionals or family where a patient is able to independently manage his medication. 6 ACTION SHOULD BE TAKEN In my opinion urgent action should be taken to prevent future deaths and I believe you and/or your organisation have the power to take such action. 2 7 YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by the 16th March 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: (1) (2) (3) (4) Care Quality Commissioner 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. 9 Dated Signed 19h January 2023 Stephen J Nicholls 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.
Senior Leadership Team Dorset Council, County Hall, Colliton Park, Dorchester, Dorset DT1 1XJ www.dorsetcouncil.gov.uk Mr Stephen John Nicholls Assistant Coroner The Coroner’s Office for the County of Dorset Town Hall BOURNEMOUTH BH2 6DY Date: 16 March 2023 Ref: Officer: Chief Executive Dear Sir Regulation 28: Prevention of Future Deaths Report Response Deceased: Mr Derek Larkin (DOB 10 Jan 1964, DOD: 1 Jun 2021) I write following the inquest held on 12 January 2023 following the investigation into the death of Derek Larkin. I would firstly like to offer my condolences to the family and friends of Mr Derek Larkin. This is a response to the Regulation 28 report issued to Dorset Council dated 19 January 2023. The Regulation 28 report sets out the following concerns affecting Dorset Council: “There is no evidence that the Dorset Council Adult Social Care computer system Mosaic can communicate with the NHS SystemOne. The Adult Social Care team would benefit from having information about the medication being prescribed to a patient, with the patient’s consent, and when that medication was last reviewed. Dorset Council Adult Social Care would benefit from information held by a current or former GP practice as to a patient’s medication and how to manage any particular concerns raised by health care professionals or family where a patient is able to independently manage his medication.” Background to Dorset Council’s involvement Dorset Council assessed Mr Larkin on 23rd April 2021 under the Care Act 2014 and he was found to have eligible needs for care and support. At this time Mr Larkin was considered to have mental capacity to make his own decisions, as per the principles of s.1 of the Mental Capacity Act 2005. Dorset Council supported Mr Larkin with his discharge from hospital back home on 20th May 2021 with a package of care. For a number of years prior to this discharge from hospital Mr Larkin had owned a medicine safe as a mechanism to manage his addiction to opioids. Response to Concerns Dorset Council have consulted with Dorset Healthcare about the medication management issues raised by this Regulation 28 report. Dorset Council understand that a separate response to the report in relation to medication management will be submitted on behalf of Dorset Healthcare/NHS Dorset Integrated Care Board. It is recommended that this response be read in the context of the response from Dorset Healthcare. Of the points that Dorset Council is able to comment upon, the Regulation 28 report highlighted that: “Dorset Council Adult Social Care would have benefitted from having knowledge of the medications that had been prescribed, together with further information from the GP practice.” And that: “There is no evidence that the Dorset Council Adult Social Care computer system can communicate with the NHS SystemOne.” In addition: Plus: “Dorset Council Adult Social Care would benefit from information held by a current or former GP practice as to a patient’s medication and how to manage any particular concerns raised by health care professionals or family where a patient is able to independently manage his medication.” It is acknowledged that health and social care services do not have one universal record keeping system. This is both a local and national issue. Due to this, various efforts have been made to create ‘bridging’ systems to improve record sharing where a patient consents for this to happen. SystemOne (a health service record keeping system) and Mosaic (Dorset Council’s social care record keeping system) are not designed to communicate with one another and are owned and regulated by separate organisational data controllers under the General Data Protection Regulation (GDPR) and Data Protection Act 2018. A System called Dorset Care Record (DCR) has been put in place which enables some information from health and social care systems, subject to an individual’s consent, to be shared across both systems on a view only access basis. The DCR is a partnership supported by NHS Dorset Integrated Care Board, Dorset County Hospital, University Hospitals Dorset, Dorset HealthCare, Dorset Council, and Bournemouth, Christchurch and Poole Council. This system was in place during the events that lead to Mr Larkin’s death. Information about medication was viewable by users of Dorset Care Record during this time. However, even with improved systems, such as these, the following points apply: 1. A person with capacity to make decisions for themselves will need to consent to sharing of information between different organisations and individuals can opt out of the DCR. 2. If a person lacks capacity to make decisions for themselves, in particular, about their care and support or medication the process in terms of sharing information between organisations may differ. Following an assessment of capacity that determines the person lacks capacity to make the particular decision in question will thereafter require best interest decision making on their behalf which will include relevant persons involved in their care. With decisions relating to medication, this will often be led by Health rather than Adult Social Care. 3. It is down to each contributing organisation as to what level of patient data is shared across the Dorset Care Record platform. For these reasons, record sharing between local authority and NHS based records is not integrated and relies upon these two standalone systems having content shared via third party applications, or manually by users, to the extent permitted by law. Due to DCR, Dorset Council did have access to medication information and did act upon the presenting risks during the events leading up to Mr Larkin’s death. It is accepted that the health service must be consulted on medication, its use/storage and risks. However, beyond this, there are prescriber risk management issues raised in the report that a local authority is unable to accept responsibility for (medication prescription and medication risk management is not a function of a local authority under the Care Act 2014) and must therefore direct the coroner to responses from the NHS. Further to this, an action plan was completed by Adult Social Care, which was provided to the Coroner in advance of the inquest setting out other actions to be taken by Dorset Council following Mr Larkin’s death. This confirms at point 5 of the action plan: “Liaison with Health professional/prescriber for reviews of medication, options appraisal and confirmation of risks and safe management” As actions around this Adult Social Care considered the following is required in future cases: 1. Ensure that Health is consulted on medication, its use, storage and any risks at assessment and review points. 2. Confirmation from Health in writing of any known risks linked to the use of specific medications for named individuals and how to safely manage these. The learning recommended from the action plan was shared with relevant managers in February 2023, as indicated would occur in the action plan. The Care Act 2014 and the statutory Care and Support Guidance does require and allow collaboration, cooperation and sharing of information between local authorities and other organisations that have functions in relation to care and support, in particular sections 6 and s.7 of the Care Act 2014. Dorset Council will continue to have regard to the relevant law and guidance for sharing of information with other organisations in cases where this is required. I hope that the information outlined in this response assists the coroner and responds to the key concerns highlighted in respect of sharing of information between organisations, in particular in respect of medication. Yours faithfully Chief Executive
Vespasian House Barrack Road Dorchester Dorset DT1 1TG 16 March 2023 PRIVATE AND CONFIDENTIAL Mr Stephen Nicolls Assistant Coroner The Coroner’s Office for the County of Dorset Town Hall Bournemouth BH2 6DY Mr Nicolls RE: DEREK GORDON LARKIN, I am writing to you in response to your letter dated 19 January 2023 regarding your investigation into the circumstances surrounding the death of Derek Gordon Larkin. We take our responsibility to act on the learning from serious incidents seriously and having considered the Coroner’s concerns (Para 5) and the actions that should be taken (Para 6), I offer you this response. Individual patient level information is accessible to health and social care staff via the Dorset Care Record (DCR). The DCR has been available since February 2018 and will include details of current and historic prescriptions. I can confirm that this gentleman has had a DCR since February 2018 which has been accessed by health and social care staff. The DCR continues to be developed and refined and I have shared your findings with the relevant teams to inform any future improvements. Further information related to the DCR is available via the following link: Dorset Care Record (dorsetcouncil.gov.uk) I hope the information I have offered provides assurance that the findings of your investigation and the area you have highlighted for the prevention of future deaths remains the focus of our continued commitment to supporting the safety and wellbeing of everyone who uses NHS services. As you may be aware NHS Dorset Integrated Care Board, is a newly formed organisation, which came into being on 1st July 2022, taking over the responsibilities from NHS Dorset CCG. I was appointed as Chief Executive for this new organisation and would therefore be the primary contact for any future communications. If it would be helpful to have a conversation to outline the changes that are taking place in the NHS in Dorset, I would be very happy to do so. Yours sincerely Chief Executive Officer NHS Dorset
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