Prevention of Future Deaths reports · 2023
Regulation 28 report to prevent future deaths, reference 2023-0301, written 18 Aug 2023. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 18 Aug 2023 |
|---|---|
| Reference | 2023-0301 |
| Deceased | Juanita Nti |
| Coroner | Andrew Harris |
| Coroner area | London Inner (South) |
| Category | Child Death (from 2015) |
| 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 1. CORONER I am Andrew Harris, Senior Coroner, London Inner South 2. CORONER’S LEGAL POWERS I make these reports under paragraph 7, Schedule 5, Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. 3. INQUEST On 9th September 2020 Miss Juanita Boate Nti (ref 9210617), died aged 4 months, in a Paediatric Intensive Care Unit. A post mortem examination was conducted, indicating an overdose of morphine. An inquest was opened on 10th March 2021 and concluded on 27th July 2023. The medical cause of death was found to be 1a Townes-Brocks syndrome with tracheal stenosis and complex congenital heart disease, following accidental morphine overdose. 4. CIRCUMSTANCES OF THE DEATH Juanita was born on 12th May 2020 and investigations determined that her complex congenital diseases were not treatable. She received palliative care from 1st July and was tenderly cared for by her parents at home with a symptom management plan devised by specialists, which included Morphine solution via her naso-gastric tube as needed. On 3rd September her condition suddenly deteriorated after a dose of morphine and she suffered a respiratory arrest on the way to hospital. She improved with urgent medication to reverse the effect of morphine intoxication, but went on to require intubation. She breathed regularly on pressure support but could not sustain spontaneous ventilation after extubation. Neither the Symptom Control Plan nor prescription written by the GP, just before a Bank Holiday during the pandemic, stipulated the volume of morphine solution to be administered and although the correct dose was stated, in error two concentrations were on the prescription. The pharmacist did not notice the error and failed to write the volume of the solution to be administered. She died of a combination of natural disease and accident. The failures of both the GP and pharmacist to make further enquiries to ensure the medication administration was safe related in part to the workload pressures of the pandemic. But they contributed to the death, as the child was given twenty times the intended dose. Juanita was very fragile with limited life expectancy, but would not have died when she did, without the overdose, naturally having less reserve to recover from the intoxication. 5. THE CORONER’S MATTER OF CONCERN During the course of the inquest the evidence revealed matters giving rise to concern, which trigger my statutory duty to report to you. The hospital originally prescribed 120 micrograms of morphine sulphate 6 hourly and dispensed 100 micrograms per ml solution, but the strength and volume to be administered were not clearly recorded on the plan sent to the GP. The mother requested her GP by telephone to continue the prescription. The GP found only one strength of morphine on the EMIS prescription system, 10mg/5mls, confirmed to be the lowest strength available in the British National Formulary. He wrote this in the first line of the prescription and then confusingly further added “100 micrograms per ml solution, 120 micrograms 6hrly”. The pharmacist did not notice that the second line contained a different concentration and dispensed the higher dose without stipulating the volume to be administered. The baby received 3mg instead of the intended 150 micrograms. Whilst both GP and pharmacist made errors in clinical practice and did not contact each other, the error would not have occurred had another strength of morphine been a choice on EMIS. EMIS have been notified and placed the special prescription on its drug data base. The local commissioning group is conducting a project to identify other special prescriptions that are not on EMIS that may pose a similar risk to safety. 6. THE REPORT IS BEING SENT TO: Chief Executive of NHS England, Skipton House, London, SE1 6LH 7. ACTION SHOULD BE TAKEN Local partnership work between hospital, general practice and pharmacies has led to revised repeat prescription polices, improved standard operating procedures, a revised paediatric formulary and overall improved safety of paediatric prescribing. One of the paediatricians involved in the tragedy informed the court that a similar incident had occurred in North of England. He understood that the lessons of our fatal incident had not been applied there and that that there was a potential to prevent other deaths by ensuring that the whole of the NHS saw the benefits of local health economy wide paediatric prescribing policies. In my opinion action should be taken to prevent future deaths and I believe your organisation has the power to take such action. 8. YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by Friday, 13th October 2023. I, the coroner, may extend the period. If you require any further information or assistance about the case, please contact the case officer, 9. COPIES and PUBLICATION I have sent a copy of my report to the Chief Coroner and to the following Interested Persons - family Pharmacy for Clapham Law Solicitors representing the for Clyde & Co representing for Gordon Solicitors representing Millennium Senior Safeguarding manager of Lambeth Child Safeguarding Board. I have also sent it to: , consultant paediatrician, The Royal College of Paediatrics and Child Health, The Royal College of General Practitioners and The Royal Pharmaceutical Society, who may find it useful. The Department of Health 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. 10. [DATE] [SIGNED BY SENIOR CORONER] Friday, 18th August 2023 A N G Harris
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.
Andrew Harris
Southwark Coroner’s Court
1 Tennis Street
London
SE1 1YD
Dear Coroner,
National Medical Director
NHS England
Wellington House
133-155 Waterloo Road
London
SE1 8UG
13 November 2023
Re: Regulation 28 Report to Prevent Future Deaths – Juanita Boate Nti who
died on 9 September 2020.
Thank you for your Report to Prevent Future Deaths (hereafter “Report”) dated Friday
18 August 2023 concerning the death of Juanita Boate Nti on 9 September 2020. In
advance of responding to the specific concerns raised in your Report, I would like to
express my deep condolences to Juanita’s parents and family. NHS England are keen
to assure the family and the coroner that the concerns raised about Juanita’s care
have been listened to and reflected upon.
Your Report raises the concern that clinical practice errors were made regarding the
prescription of and dispensing of oral morphine preparation to be administered to
Juanita. Further, that the error would not have occurred had the lower strength of
morphine been a choice on the EMIS prescription service and that the whole of the
NHS should ensure local health economy wide paediatric prescribing policies.
NHS England is aware that in the last three years, there have unfortunately been three
serious incidents where an incorrect oral morphine preparation was prescribed and
dispensed to a baby. We are aware that issues have included a lack of awareness
and clarity over a medicine being a special preparation as well as poor communication
between medical professionals and with the parents of the child.
National work is underway by paediatric experts to consider what needs to be done to
reduce the likelihood of a recurrence. This work incorporates several related
workstreams including a specials formulary, with standardisation of strengths of
paediatric oral liquids, recognition in NHS payment schemes, national guidelines,
standardisation of RAG lists1 and a national approach and input into GP Prescribing
systems, including using the NHS dictionary of medicines and devices (dm+d) codes
for special prescriptions. The dm+d is a dictionary of descriptions and codes which
represent medicines and devices in use across the NHS. It must be used when
electronic systems exchange or share information about medicines relating directly to
a patient’s care. I note from your Report that EMIS have already placed the special
prescription on its drug data base.
1 RAG stands for red, amber, green and the RAG List provides professional guidance for practitioners
in both primary and secondary care as to where responsibility should sit for prescribing.
The national Patient Safety Team at NHS England are aware of the issues and the
Royal College of Paediatrics and Child Health (RCPCH) and the Neonatal and
Paediatric Pharmacy Group (NPPG) Joint Medicines Committee is currently
undertaking a ‘Review of the Management of the Supply of Unlicensed Liquid
Medicines to Children’, which includes the workstreams referenced above. NHS
England awaits a statement from the Group as to next steps later in November 2023,
and further actions and discussions will then then take place. We can update the
Coroner once we have an update.
NHS England also understands that the Advisory Council on the Misuse of Drugs’
Technical Committee is reviewing the safety of liquid morphine and will carefully
consider outcomes and recommendations arising from this.
There is also national guidance from the National Institute for Health and Care
Excellence (NICE) on End of life care for infants, children and young people with life-
limiting conditions and guidance on the use of morphine in palliative care and young
children: Morphine | Drugs | BNF | NICE
At a more regional level, a Patient Safety Learning Bulletin was circulated across
South East London by South East London Clinical Commissioning Group (since
replaced by South East London Integrated Care Board (ICB)) following this incident.
This included key learning points relating to prescribing and dispensing of unlicensed
specials. A ‘Specials Team’ has also been established which works across the whole
health system and has incorporated work relating to the outcomes of the Serious
Incident Report that reviewed the circumstances of Juanita’s death. Broader work on
the EMIS formulary is also progressing with the ICB’s Children and Young People’s
Formulary Team to rationalise the number of oral liquid options from which products
can be chosen.
Other London systems have also undertaken work in this area, for example North
East London have undertaken local work to align their internal formulary against the
national list of recommended strength specials in 2019, and updated these again in
2021: Standardised strengths of liquid medicines for children – NPPG.
The London region Controlled Drugs Accountable Officer will also be discussing this
issue with all London ICB medications safety representatives and ensure regional
oversight of implementation of action plans which will include communications to
GPs and community pharmacists.
NHS England is also aware that of work being undertaken in other regions, including
the North East, on this issue.
I would also like to provide further assurances on national NHS England work taking
place around the Reports to Prevent Future Deaths. All reports received are discussed
by the Regulation 28 Working Group, comprising Regional Medical Directors, and
other clinical and quality colleagues from across the regions. This ensures that key
learnings and insights around preventable deaths are shared across the NHS at both
a national and regional level and helps us pay close attention to any emerging trends
that may require further review and action.
Thank you for bringing these important patient safety issues to my attention and please
do not hesitate to contact me should you need any further information.
Yours sincerely,
National Medical Director
See every Prevention of Future Deaths report matching Child Death (from 2015), and how often a new one appears.
What would an alert for this have sent me? Search the full text
Free to try — the preview shows the real matches and how many arrived in the last 12 months. Your first email alert is free.
These reports are published by the Chief Coroner's office at judiciary.uk and are © Crown copyright. The text here is reproduced from the published PDF so it can be searched. If something on this page is wrong, or you are a person named in it and want it reviewed, email drcjar@gmail.com and we will act promptly.