Prevention of Future Deaths reports · 2023
Regulation 28 report to prevent future deaths, reference 2023-0213, written 26 Jun 2023. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 26 Jun 2023 |
|---|---|
| Reference | 2023-0213 |
| Deceased | Matthew Power |
| Coroner | Susan Ridge |
| Coroner area | Surrey |
| 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 THIS REPORT IS BEING SENT TO: 1. 1 CORONER , Chief Executive Officer, EMIS Health Susan Ridge, HM Assistant Coroner for Surrey. 2 CORONER’S LEGAL POWERS I make this report under paragraph 7(1) of Schedule 5, to The Coroners and Justice Act 2009. 3 INVESTIGATION and INQUEST An inquest into the death of Matthew William Thomas Power was opened on 29 September 2022 and resumed and concluded on 14 June 2023. The medical cause of death given was: 1a. Mixed Drug Toxicity. And I determined that Matthew William Thomas POWER died on 17 June 2022 at 01:30 hours at a house in Redhill, Surrey having taken illicit and prescribed drugs over the previous 36 hours resulting in his death from mixed drug toxicity. My conclusion was this was a drug related death 4 CIRCUMSTANCES OF THE DEATH Mr Power was a 33 year old man living in supported accommodation. He had a history of mental health issues and had been diagnosed with Dissocial Personality Disorder. He also had a history of drug and alcohol abuse dating back to his teenage years. He had been known to take impulsive overdoses of drugs including prescription drugs ( ). On the afternoon of 15 June 2022, Mr Power visited friends in the Redhill area and with them bought and took drugs throughout the next 36 hours until his death in the early hours of 17 June 2023. Toxicology revealed a very high level of cocaine (potentially lethal in itself). It also showed heroin, methadone (which was not prescribed) and codeine at levels that that any 1 of those drugs could have been lethal on its own, but that each opioid was likely to have increased the toxic effects of the other. The codeine was from ingestion of co-codamol. Apart from his mental health medication, Mr Power was prescribed co- codamol for pain relief. He had been prescribed this medication both by his current (since 2020) and previous GPs. It was latterly prescribed because of stockpiling concerns; he had frequently requested co-codamol. In evidence it was accepted that there had been errors in prescribing so that on 14 June 2022 Mr Power collected co-codamol tablets from a local chemist (but not his usual chemist) whilst still receiving his regular prescriptions . 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 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. The GP practice uses EMIS for patient records and prescribing. From the evidence it appears that when one doctor ends a repeat prescription on EMIS, it remains in the 'pending' Medication Management box of the doctor to whom it was originally sent. Creating the risk, as in this case, that as a pending prescription it is actioned and issued instead of cancelled. 2. I heard evidence that the EMIS system appears to group prescriptions into the amount prescribed rather than simply recording when a prescription is issued. In this case there were different entries grouped as 100 tablets, 50 tablets, 30 tablets, and 24 tablets. Consequently, it was not clear to the duty doctor that the most recent prescriptions for co-codamol had been for a shorter course of only tablets and as a result tablets of co-codamol were prescribed and issued. 3. Evidence was given by the GP practice that to interrogate the EMIS system in order to ascertain what had actually been prescribed, issued and when, was a challenging task; it had taken 3 GPs and the in-house pharmacist to conduct the review. 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you 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 21 August 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: Mr Powers family Greystone House Surgery Copy Also to: ICP Chair Surrey Heartlands Health and Care Partnership (Integrated Care System 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 other 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. 9 Susan Ridge 26 June 2023 3
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.
FAO Susan Ridge, Assistant Coroner HM Coroner’s Court Station Approach Woking Surrey GU22 7AP 14 August 2023 Ref: REGULATION 28 – Matthew William Thomas Power Dear Ms Ridge, We write in response to the Regulation 28 report dated 26th June 2023 (the “Report”). We were saddened to read of the death of Mr Power and would like to take this opportunity to express our sincere condolences to their family. As a company, we work very hard to support health care services across the UK and patient safety is of paramount importance to us. We have undertaken an internal review of EMIS Web (the “System”), focussing on the issues raised as areas of concern in the Report, namely: • Concern 1: Evidence was given that repeat prescriptions being ended by a clinician remained in the ‘pending’ medication management box (sic), purportedly creating a risk that it is actioned and issued rather than being cancelled. • Concern 2: Evidence was given that EMIS Web groups prescriptions into the amount prescribed, rather than simply recording when a prescription was issued. • Concern 3: The challenge that the Practice had with regards to ascertaining what had been prescribed. Addressing these in turn: Concern 1: repeat prescriptions being ended by a clinician remained in the ‘pending’ medication management box (sic), purportedly creating a risk that it is actioned and issued rather than being cancelled. When a clinician ends a prescription (including, any repeat prescription) in the Medication module of the System (End Course), this action ends that prescription if there are no outstanding associated Workflow tasks (as discussed in further detail below). If, however, a clinician attempts to End Course and there is an outstanding associated Workflow task, a warning box will pop up on screen that states “cancelling an issue is not possible when there are pending requests”. This means it is clear to the relevant clinician that the prescription has not successfully ended and acts as a prompt for them to review the outstanding Workflow task. In relation to outstanding Workflow tasks, in addition to the immediate on-screen prompt in relation to an attempt to End Course, each time the relevant clinician logs in to the System, there is a task bar at the top of the home page which indicates how many outstanding Workflow tasks there are for each section within the System. As an illustration, there may be 5 outstanding Workflow tasks in the “Medicines Management” tab within the System, and this will show as “Medicines management – 5”. The clinician would then click on that tab, which takes them to their Clinician specific Workflow page. It is also possible for a clinician to view global tasks, i.e. those outstanding tasks for the entire practice (and outside of their specific Workflow). When a repeat medication prescription has been ended, it automatically moves to ‘Past Medication’. Any requests subsequently placed for that same medication item can only be actioned in one of two ways: either ‘restart’ the medication or ‘reject’ the request (shown below in Fig 1), both of which require a prescribing Clinician to use their clinical judgement in order to ascertain whether to accept or reject such a request. Fig 1. In summary, there are mechanisms in place designed to ensure that where steps have been taken to end a repeat prescription the relevant clinician will be prompted to take a positive action to review the same. Concern 2: EMIS Web groups prescriptions into the amount prescribed, rather than simply recording when a prescription was issued. Medications are grouped within the System with the following “view” options: (i) Acute/Repeat; (ii) EMIS Drug Group; (iii) Problem Orientated View; (iv) Acute/Repeat (Alphabetical); or (v) no grouping (as shown in the dropdown option in Fig 2). As a default, medications are displayed as Acute/Repeat, which will show medications in chronological order of date last issued. An individual user of the System can choose which view to use. Regardless of which view option is chosen, a Clinician would easily be able to see the last issue date of any particular drug, as demonstrated in the same Fig 2 below (towards the right-hand side of the view screen). Fig 2. In summary, it is open to the relevant clinician to configure their view as required. Concern 3: challenges that the Practice reported having with regard to ascertaining what had been prescribed. The System has a Drug History function (within the Medication module) which allows users to view the timeline of any actions performed against each medication entry within the patient record by right-clicking on the relevant medication and choosing “Drug History” (as shown in Fig 3). This includes dates and times a course was commenced, modified, or ended, as well as when requests for medication issues were placed (shown below in Fig 4). The Drug History panel defaults the view to show the history for all courses of the same preparation (e.g., Co- codamol tablets), but also allows the user to change the view to show the history for courses for all medications with the same ingredients, (e.g., Paracetamol or Codeine) or to show the history specifically for the medication course that has been selected. Fig 3. Fig 4. The required information is therefore readily available within the System. Conclusion Based upon the information provided in the Report and our subsequent review, we do not believe there are any software developments that are required in order to mitigate risks relating to this case beyond the functionality that already exists within the System. In addition, we note that the functionality described above meets the specifications provided by NHS England. Training is provided on use of the System (including all the functions detailed in our response above) at the point of implementation. Additionally, all GP Practices are encouraged to have relevant processes in place to ensure all clinicians are up to date with their knowledge of System use. Training is further supported by a series of related online Knowledge Base articles that can be accessed, as part of self-directed learning, by EMIS users (i.e. Clinicians) at any time via the EMIS Now platform. These include articles relevant to the medication modules. EMIS are happy to provide further training, free of charge, to the Practice in relation to the optimal use of the functionality discussed in this Report. We trust that the details outlined above assist. If you have any further queries then please contact our Senior Clinical Director, , in the first instance. Kind regards Chief Medical officer, EMIS Group
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