Prevention of Future Deaths reports · 2023
Regulation 28 report to prevent future deaths, reference 2023-0384, written 12 Oct 2023. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 12 Oct 2023 |
|---|---|
| Reference | 2023-0384 |
| Deceased | John Hoare |
| Coroner | Crispin Oliver |
| Coroner area | West Yorkshire Western |
| Category | Hospital Death (Clinical Procedures and medical management) 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 Low Moor Medical Practice 1 CORONER I am Crispin OLIVER, HM Assistant Coroner for the coroner area of West Yorkshire Western Coroner Area 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 15 April 2020 I commenced an investigation into the death of John HOARE aged 62. The investigation concluded at the end of the inquest on 12 October 2023. The conclusion of the inquest was that: John Hoare died a natural death occurring while, preventably, detained under the Mental Health Act 1983. 4 CIRCUMSTANCES OF THE DEATH John Hoare was born on 03 February 1958. He died at 06.30am on 31 March 2020 at Airedale General Hospital. He had a diagnosis of schizoaffective disorder. He had admissions at Bradford Royal Infirmary between 15 November and 04 December 2019 and 14 December and 14 January 2020. He suffered from confusion, cognitive and memory problems and lithium toxicity. He was discharged from Bradford Royal Infirmary to Norman Lodge Care Home. This resulted in a change of medical practice from Shipley to Low Moor Medical Centre. Concurrently his established Community Mental Health Care Coordinator changed - he did not have one on discharge from hospital. The new one was allocated on 24 January and was able to first meet with John on 05 March. John required a number of prescribed medications for his condition, including, crucially, lithium citrate. This was clearly referenced in the discharge letter and the Norman House care plan. Lithium was dispensed and administered between 15 and 24 January per his prescription. It was not supplied with the next 28 days medication. On 20-21 January a decision was made by GPs that blood tests were required before the prescription for lithium could resume. These confirmed by 04 February that John`s lithium was below therapeutic levels. For the purposes of the next prescription period, commencing from 17 February, however, lithium was not included. There had been GP oversight of this but there was a failure to recognise and act on the omission. John`s mental health declined critically from 03 march 2023. Advanced Nurse Practitioners attended Norman House 2-3 time per week. On 04 March, for the first time, an Advanced Nurse Practitioner examined John. She said she would prescribe lithium. It was dispensed and administered on 05 March. Therefore John did not receive lithium between 24 January and 05 March. By the time it was resumed his condition was so severe that he required to be detained under Section 4 of the Mental Health Act 1983, in the early hours of 06 March 2020. He was admitted to the Bracken and then Fern wards of Airedale Centre for Mental Health. While admitted, albeit there were no other reported cases among staff or residents, he contracted Covid 19. This required his admission to Airedale General Hospital on 27 March 2020, where he subsequently died. He remained Regulation 28 – After Inquest Document Template Updated 30/07/2021 detained under section at the time of his death. James had been in a dependent position while at Norman House. Lithium could have resumed no later than 04 February and should have resumed no later than 17 February 2020, and it did not. There was a gross failure to provide basic medical attention insofar as: there was reference to lithium on the discharge summary; Johns's case required specific attention; there was obvious evidence on system 1 available to be seen; John`s needs as a new patient should have been carefully considered; lithium prescribing, dispensing and administration should attract particular care and attention; there was an inherent importance in not delaying or interrupting lithium; there had been numerous requests and reminders from the care home about the provision of lithium; there was a material delay during which nothing was done by the GPs` surgery; there was failure to identify that delay; that failure led to the precise consequence that the lithium was intended to avoid. As a result of this gross failure, John required to be detained and admitted to Airedale Centre for Mental Health. The omission of the lithium contributed to his condition more than other factors. John contracted Covid 19 while admitted at Airedale Centre for Mental Health, most likely in the Fern Ward, possibly from a member of staff. While it is possible that he was at a greater risk of infection while in the Fern Ward than he would have been at Norman House, or any other environment at that time, it cannot be so concluded on a balance of probabilities. Therefore it cannot be concluded, on a balance of probabilities, that his death from Covid 19 was caused by his being detained under section, albeit the detention was preventable. 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) Firstly, it has to be recorded that the GP who gave evidence for Low Moor Medical Centre was a conspicuously honest witness and clearly exceptionally caring. He had been devastated by what had occurred in this case. But the fact remains, secondly, that there had been a gross failure to provide basic medical attention in relation to lithium prescribing and dispensing that resulted in John being sectioned. While a finding, on the balance of probabilities, that the detention caused the death was not available, it does remain a possibility. 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. 7 YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by December 07, 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 Regulation 28 – After Inquest Document Template Updated 30/07/2021 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: 12/10/2023 Crispin OLIVER HM Assistant Coroner for West Yorkshire Western Coroner Area 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.
Low Moor Medical Centre
29 The Plantations
Bradford
BD12 0TH
Mr Crispin Oliver
HM Assistant Coroner
Western Area of West Yorkshire
Dear Mr Oliver,
RESPONSE TO CORONER'S REGULATION 28 ORDER
I am writing to provide a response to the Coroner's Regulation 28 Order issued in
connection with the recent case of Mr John Hoare, deceased. We acknowledge and
appreciate the importance of your inquiry and are committed to cooperating fully.
Compliance with the Order: We want to assure you that Low Moor Medical Practice is
fully committed to complying with the Coroner's Regulation 28 Order. We understand
the significance of the information requested and the implications it holds for the
prevention of future deaths.
We have carried out internal review to gather all relevant information pertaining to the
incident in question. As explained in my witness statement, we carried out our first
meeting about our failure to issue Lithium medication on the 5th of March 2020, the
day before Mr Hoare required detention under the mental health act. This indicates
that we recognised the severity of the failure to issue lithium medication. We realised
that we needed to revise our practice. As Lithium is a shared cared drug, indicating
that it is a drug with increased risk associated with it, the joint action of both
secondary care and primary care
its appropriate and safe
administration. The supervision of such shared care drugs falls outside the standard
GMS contract and is covered by separate guidelines, which can be found here.
Shared care guidelines - South West Yorkshire Area Prescribing Committee
(SWYAPC)South West Yorkshire Area Prescribing Committee (SWYAPC).
is required
for
We are actively collaborating with South West Yorkshire Area Prescribing committee,
Bradford District Care Trust and Bradford District and Craven Health and Care
Partnership, who have taken on board the concerns with regard to Lithium
prescribing in general and specifically in regard to patients transferring between
different care providers.
The new guidance for prescribing Lithium is to be found here. Final_-Lithium-amber-
guidance-approved-23_03_2023-1-1.pdf (swyapc.org) and is also attached to this
response.
This issue took place involving a “Shared care Drug” prescribed to a patient in an
“Intermediate care Unit”. Both Shared care Drugs and Intermediate Care units our
outside Core General Practice and are covered by Local Enhance Services. The
Shared care medication LES covers care in General Practice of patients while they
are stable on medication. This patient had been discharged from hospital after
admission with Lithium toxicity – by definition – not stable.
We do however accept that mistakes were made in the practice, and I have listed
below measures we have put in place aimed at preventing future recurrence.
Norman lodge - Change to Temporary Registration.
We have made the significant change that patients admitted to Norman Lodge will
only be registered as Temporary Residents. This keeps their home practice “in the
loop”. We made this change 1/11/23. The original request for medication went from
the care home to the original practice who did not prescribe because the patient was
no longer registered with them. This is because our previous practice was to fully
register patients in Norman Lodge. This is a significant improvement in continuity of
care, enabling patients to remain with a practice that is familiar with the needs of
these often complex patients.
Pick up shared care in New Patients.
We had processes in place to deal with prescribing reviews for new patients joining
the practice, existing patients on shared care drugs, and prioritising new admissions
to the intermediate care unit. Unfortunately, this case involved a combination of all
three of these and there was a breakdown in the process. This was exacerbated by a
hiatus in mental health care coordinator provision (nb a different role form the care
coordinators mentioned below) as Mr Hoare’s previous care coordinator left in
December 2019 and he was not seen by his new coordinator until March 2020, by
which time his mental health had already deteriorated gravely.
Medications to always issue.
The Clinical Pharmacists are now aware of which medications (including shared care
medications) need to be issued without interruption. In this case they were waiting for
a Lithium level before issuing but this should not have happened.
Community Advanced Nurse Practitioner for care Home.
Since August 2023 we have employed a full time experienced ANP (16 years as a
community Matron). Previously we had someone in post only 2 days a week. This
has allowed greater oversight of these patients in the Intermediate Care beds. We
are also discussing with the local Consultant Geriatrician about involving their team
directly as many of these patients have been discharged from their hospital units to
these beds.
Lithium results.
I am in discussion with our local Pathology laboratory about ensuring that Lithium
results come to us as an individual result and not buried in a long list of Biochemistry
results. This should reduce the risk of any Lithium result being overlooked.
Ongoing care of patients on shared care drugs.
I have started a discussion with
, Medical director of Bradford district
care trust, regarding the practice of discharging some patients on shared care
medication from the mental health team, so that they are under the sole care of the
primary care team (General Practice). Whilst not directly applicable in Mr Hoare’s
case, this practice leads to increased risk in a vulnerable group of patients, and we
are aiming to ensure that this practice does not continue.
Distribution of learning points and actions.
is on the Local Medical committee and is
Our senior partner,
ensuring that the findings of Mr Hoare’s inquest are known to other practices within
the Bradford District and Craven health care partnership.
This document will be discussed at our regular practice meeting in order to ensure
that appropriate clinicians are familiar with the shortcomings that occurred in this
case and the actions taken above.
The practice will ensure that these changes are audited on an annual basis, so that
these measures can be reviewed and modified appropriately.
I trust that this document will be accepted as a reasonable response to your
Regulation 28 order.
If you need further information, please do not hesitate to contact me at the practice.
Yours sincerely,
GP Partner
Low Moor Medical Practice
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