Jacqueline Carrey

Regulation 28: REPORT TO PREVENT FUTURE DEATHSNOTE: This form is to be used after an inquest.REGULATION 28 REPORT TO PREVENT DEATHSTHIS REPORT IS BEING SENT TO:1 Milton Keynes University Hospital Chief Executive1CORONERI am Tom OSBORNE, Senior Coroner for the coroner area of Milton Keynes2CORONER’S LEGAL POWERSI 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 2013.3INVESTIGATION and INQUESTOn 01 June 2023 I commenced an investigation into the death of Jacqueline Anne CARREY aged 56. The investigation concluded at the end of the inquest on 18 October 2023. The conclusion of the inquest was:Drug related4CIRCUMSTANCES OF THE DEATHThe deceased was admitted to Milton Keynes University Hospital on the 11th May 2023 due to extreme pain from pancreatitis. She was discharged from hospital on the 16th May 2023 with an excess of  medication despite warnings recorded that her medication should be restricted to seven days supply. She was found deceased at home   Milton Keynes on the 25th May 2023 and the cause of death was  toxicity.5CORONER’S CONCERNSDuring 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:There may not have been a clear indication on the patients medical record about the potential risk of  abuse, or for the risk to be flagged up to members of staff before discharge. This oversight raises serious questions about the hospital's processes and procedures for managing  medication and patient records. I strongly urge the hospital to undertake a comprehensive review of the procedures concerning the distribution of medication. It is imperative that the hospital ensures that the potential risks and warnings are clearly marked on the patient's medical record and that all staff are made aware of any potential concerns regarding  use. I believe that a thorough review of your procedures and the implementation of more robust protocols can protect the well being of patients and prevent future similar deaths.6ACTION SHOULD BE TAKENRegulation 28 – After InquestDocument Template Updated 30/07/2021 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.7YOUR RESPONSEYou are under a duty to respond to this report within 56 days of the date of this report, namely by December 21, 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.8COPIES and PUBLICATIONI have sent a copy of my report to the Chief Coroner and to the following Interested PersonsI have also sent it to  (sister of Mrs. CARREY), Chief Executive of Milton Keynes University Hospital and the Care Quality Commission.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.9Dated: 26/10/2023Tom OSBORNESenior Coroner forMilton KeynesRegulation 28 – After InquestDocument Template Updated 30/07/2021

Mr Tom Osborne 
HM Senior Coroner  
Milton Keynes City Council 

14 November 2023 

Dear Mr Osborne 

Regulation 28 Report following an Inquest into the death of Mrs Jacqueline Anne 
Carrey 

I am writing following receipt of a regulation 28 Report, following on from the Inquest 
concluded on 18 October 2023. Mrs Carrey died on account of opioid toxicity 9 days 
after discharge from hospital. She had a long history of opioid use, and the potential 
for misuse had been noted in that community dispensing of some of her medicines 
had  been  restricted  to  a  7-day  supply.    This  7-day  restriction  was  identified  by 
colleagues here in the hospital, but this information was not effectively communicated 
to all parties involved in Mrs Carrey’s admission and subsequent discharge: she was 
discharged  on  16  May  2023  with  a  14-day  supply  of  medicines  with  a  potential  for 
misuse (including opioids). Whilst difficult to be sure of the precise circumstances, it is 
likely that this excess supply contributed to Mrs Carrey’s subsequent death through 
opioid toxicity.  

In  order  to strengthen  measures  in  place  which  may  reduce  the  risk  of  recurrence, 
there are two underlying processes which are pertinent: (1) medicines reconciliation 
and  (2)  procedures  for  the  prescription,  validation  and  dispensing  of  discharge 
medications.  

Medicines reconciliation is a multi-stage process whereby the patient’s medicines 
history is understood and recorded by hospital staff. It typically involves three steps:  

1.  A  medication  history  is  taken  and  recorded  in  the  Electronic  Health  Record 
(EHR)  by  the  assessing  clinician.  This  medication  history  would  usually  be 
taken directly from the patient or their carer. It may or may not involve review 

 
 
  
 
 
 
 
 
 
 
 
 
 
 of repeat prescription forms or hand-written records proffered by the patient. It 
may involve review of medicines themselves (e.g., bags or boxes of medicines 
brought to the hospital, or a multi-dose container – ‘Dosette box’ – prepared 
either  by  the  patient  or  the  community  pharmacy).  Increasingly,  assessing 
clinicians  will  access  primary  care  prescribing  information  with  the  Health 
Information  Exchange,  HIE  (a  window  from  the  hospital’s  eCare  system  into 
elements of primary care’s SystmOne record).  

2.  The next stage is typically undertaken by a registered Pharmacy Technician. 
This involves the confirmation and recording of the patient’s medicines history 
from two separate sources – e.g., the patient and primary care records. This 
step  may  on  occasion  be  a  repetition  of  the  initial  history  described  above. 
However,  the  process  is  more  standardised,  and  will  include  all  medicines 
whilst  the  work  of  the  assessing  clinician  (above)  will  inevitably  focus  on 
medicines  pertinent  to  the  presenting  complaint  and/or  those  deemed  to  be 
‘high risk’ (if missed etc…). This medicines history work is recorded within the 
EHR on a form known as the ‘Pharmacy Medication History Form’.  

3.  The  final  stage  of  medicines  reconciliation  involves  a  registered  Pharmacist 
cross-checking  and  validating  the  work  undertaken  by  the  Pharmacy 
Technician. This is also recorded in the ‘Pharmacy Medication History Form’.   

The medical record is made up of many elements: documents which form the core of 
the narrative record (e.g., entries by nurses, doctors and ward-based clinicians which 
build up over time); the prescription record or ‘drug chart’ which sits within a module 
of the record known as ePMA; and, a number of discrete forms which are part of the 
record but ‘sit in the background’ available for reference later rather than forming part 
of the readily visible narrative record.  The pharmacy steps of medicines reconciliation 
involve the ‘Pharmacy Medication History Form’ which is – appropriately – stored in 
the record for future reference rather than featuring in the headline patient narrative 
documentation.  Where  the  pharmacy  team  identifies  issues  through  the  medicines 
reconciliation  process  (for  example,  medicines  which  appear  to  be  incorrect  or 
absent),  they  bring  these  to  the  attention  of  the  medical  staff  either  through  direct 
contact  (face-to-face  or  telephone),  or  by  posting  specific  ‘pharmacy  intervention 
messages  /  alerts’  within  the  medical  record.  Prior  to  the  introduction  of  electronic 
prescribing, pharmacists would have made these interventions through use of notes 
and ‘green ink’ on the paper medicines prescription chart.     

 
 
 
 
      
 
 The  prescription,  validation  and  dispensing  of  discharge  medications  occurs 
later  in  the  patient’s  stay  as  discharge  is  being  planned.  The  precise  timing  of 
discharge can often be difficult to predict for a variety of patient-related and external 
factors.  This  means  that  sometimes  plans  for  discharge  medications  need  to  be 
confirmed  again  (or  altered)  if  an  anticipated  discharge  is  subsequently  delayed  or 
brought forward. The prescription stage is undertaken by a prescriber (usually, but 
not  exclusively,  a  doctor).  The  validation  and  dispensing  stages  are  undertaken  by 
pharmacy staff. Validation usually takes place face-to-face on the ward (although it 
can be undertaken virtually). Dispensing involves the sourcing of medicines from the 
ward  (either  from  the  patient’s  own  supplies  or,  on  occasion,  ward-held  stock)  and 
from the Trust’s pharmacy department.      

As you are aware following evidence given at Inquest, Mrs Carrey’s planned discharge 
was delayed for clinical reasons. I shall not go over events, which you heard about in 
evidence, in detail. Plans for that discharge were likely sound: opioids were prescribed 
but the pharmacist involved had identified that Mrs Carrey had a supply at home and 
therefore dispensing was not required. It is likely that the first pharmacist did look at 
the ‘Pharmacy Medication History Form’ and would therefore have been aware of the 
7-day restriction but given that no opioids were going to be dispensed at this time, the 
information was less pertinent. This discharge did not go ahead and when Mrs Carrey 
was discharged on 16 May, a second pharmacist did authorise dispensing of a 14-day 
supply of opioids. Mrs Carrey had said in the interim that she did not in fact have a 
supply at home. The second pharmacist made the – in retrospect flawed – assumption 
that  the  doctor’s  opioid  prescription  was  valid  and  did  not  repeat  this  element  of 
validation.  This  was  –  in  the  pharmacist’s  mind  –  a  question  of  supply  not  the 
appropriateness  of  the  prescription  itself.  The  second  pharmacist  did  not  therefore 
seek out and review the ‘Pharmacy Medication History Form’ where the information 
about Mrs Carrey’s 7-day supply restriction was recorded. The recording of the supply 
restriction in the ‘Pharmacy Medication History Form’ was in essence ‘free text’ – it 
was not held as codified information and did not therefore drive any particular actions 
or alerts within the EHR.   

Action Taken 

In addition to using Mrs Carrey’s case for awareness raising and education within the 
broad pharmacy team, we have reviewed our EHR to determine whether additional 
safety steps can be incorporated in such a way as they do not negatively impact the 
timeliness of high-volume processes in a disproportionate way.  

 
 
  
 
 
 We  have  been  able  to  incorporate  new  measures  which  –  at  their  core  –  codify 
information  /  recommendations  around  the  restriction  of  medicines  supplied  at 
discharge  (i.e.,  exceptions  to  the  contractual  14-day  supply  expectation).  The 
‘Pharmacy Medication History Form’ now includes the question ‘Does this patient get 
a limited supply in community’, requiring a ‘yes’ or ‘no’ answer. The user can still add 
free  text  narrative  but  the  fact  of  selecting  ‘yes’  in  response  to  this  question  fires 
specific  actions  downstream  when  clinicians  are  looking  to  progress  the  patient’s 
discharge.  

When  doctors  begin  to  prescribe  discharge  medicines,  a  prominent  ‘limited  supply’ 
alert comes to their attention. When pharmacists begin the validation process, a similar 
alert comes to their attention and clearly signposts the ‘Pharmacy Medication History 
Form’ for review prior to dispensing. Screenshots demonstrating these changes are 
appended.  

Workflows  within  Electronic  Health  Records  (EHRs)  are  relatively  standardised  by 
supplier (rather than being bespoke to individual healthcare providers). We shall share 
our learning from Mrs Carrey’s case with Oracle Cerner (global supplier of our EHR), 
both  such  that  it  can  be  shared  with  other  UK  NHS  clients  but  also  considered 
internationally.               

I trust that this response is helpful.  

Yours sincerely, 

Chief Executive 

Enclosed 

 
 
 
 
 
 
 
 
 
 
 
 
 Screenshots  in  relation  to  modified  workflows  on  supply  limitation  of  discharge 
medications