Prevention of Future Deaths reports · 2023
Regulation 28 report to prevent future deaths, reference 2023-0476, written 24 Nov 2023. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 24 Nov 2023 |
|---|---|
| Reference | 2023-0476 |
| Deceased | Zulfiqar Hussain |
| Coroner | Julie Mitchell |
| Coroner area | Manchester North |
| Category | Alcohol, drug and medication related deaths · Mental Health related deaths · Other 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 (1) REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: 1. & Partners, Croft Shifa Health Centre, Bellfield Road, ROCHDALE 1 CORONER I am Julie Mitchell, Assistant Coroner for the Coroner area of Manchester North 2 CORONER’S LEGAL POWERS I make this report under paragraph 7, Schedule 5, of the Coroner’s and Justice Act 2009 and Regulations 28 and 29 of the Coroners (Investigations) Regulations 2013 3 INVESTIGATION and INQUEST On 18 July 2023 an investigation into the death of Zulfiqar HUSSAIN was commenced. The investigation concluded at the end of the inquest on 12 October 2023. The conclusion of the inquest was drug related and the cause of death was: 1a Combined drug toxicity 1b - 1c - II Bronchopneumonia 4 CIRCUMSTANCES OF DEATH Zulfiqar Hussain was 48 years old at the time of his death. He suffered with mental health issues and was receiving mental health care from the community mental health team. He was also a chronic illicit substance user and had received regular support from Turning Point. On 2 April 2023, the deceased was found at his home address having died from combined drug toxicity leading to significant respiratory depression, which was compounded by the presence of pneumonia. It was not possible, on the evidence available, to determine whether the deceased had ingested the drugs with the intention of ending his life. During the course of the inquest, the Court heard evidence about correspondence sent to the GP practice by Turning Point and the Mental Health Team. An adverse medication marker should have been prominently placed on the deceased’s electronic medical records as a result of correspondence from Turning Point. However, this was not done. There were at least 2 occasions when correspondence from the mental health team should have prompted a clinical review by a clinician. These did not take place and the Court heard that this was most likely because the correspondence was filed by administration staff without it having been seen by a clinician. Whilst the evidence does not reach the requisite standard to show that the deceased’s death would have been averted had correspondence been reviewed by clinicians at the GP practice, it meant that opportunities to provide the deceased with support and care and to foster his engagement with health services were missed. It is regrettable that this Court has previously issued a Regulation 28 report to your practice on the lack of robust processes to ensure clinician review of correspondence and, despite assurances, the situation in which correspondence is filed by administration staff without any clinician review pertains (see Regulation 28 report dated 23 December 2021). 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 will 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) As previously raised in Report to Prevent Future Deaths dated 23 December 2021, incoming correspondence to the GP practice continues to be dealt with by administrative staff who decide whether or not it is placed before a GP. The concern is that there is no robust system in place to ensure that communication to the surgery which may require action to be taken by medical staff is brought to their attention. (2) Adverse medication markers are not being placed on computerised medical records and this creates the risk that contraindicated medications may be inadvertently prescribed. 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe each of you respectively 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 Friday 19 January 2024. I, the Assistant 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 namely:- • The family of the Deceased • Turning Point • The Care Quality Commission • The GM Integrated Care Partnership 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 from. 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. - Date: 24.11.23 Signed:
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.
THE CROFT SH/FA HEALTH CENTRE BELFIELD ROAD, ROCHDALE, LANCS. OL16 2UP Regulation 28 Report - Response 12th December 2023 Re: Death of Zulfiqar Hussain Dear Coroner Mitchell I would like to extend my sincere condolences to the family of the deceased. I also offer my apologies to yourself for the delay in responding to the initial informal request for information . With reference to the above and your concern regarding document workflow and adverse medication markers placed in medical records. 1. As previously raised in report to prevent future death dated 23 December 2021 , incoming correspondence to the GP practice continues to be dealt with by administrative staff who decide whether or not it is placed before a GP. The concern is that there is no robust system in place to ensure that communication to the surgery which may require action to be taken by medical staff is brought to their attention. Our document management was reviewed in November 2021 in response to a Regulation 28 Report issued by the coroner. We had a practice meeting and discussed the process of filing Did Not Attend notifications that were in place for secondary care services as well as screening services and '2 week wait' suspected cancer referrals. We agreed that we would amend the procedure for document management to expand the list to include the below mentioned specialities that would be sent to GP's, as a result of this incident. Please see attached Significant Event Analysis report. We have two designated members of staff who are responsible for document management within the practice. The GP's discussed and informed staff that the below noted patients are 'high risk'. The Document Management Policy was updated to reflect the changes. 2 Week Wait (Suspected Cancer) referrals. Learning Disabilities Mental Health/Depression (all patients) Safeguarding notifications Addiction Patients on Gold Standard Framework - patients who are on 'end of life pathway' . Any correspondence for patients above is to work flowed to the GP the letter is addressed to. If the matter is urgent, a medication change or a notification of patient's personal circumstance (safeguarding/abuse) this is forwarded to the GP on call. In this case the last letter received from Turning Point, Rochdale & Oldham Active Recovery service, was dated 22/3/2023. The service had a face-to-face meeting with Mr Hussain on 2/2/23 with his Recovery support worker present at the consultation . Unfortunately, I can only send screen shots of the audit trail of this letter as the document management system shows the history of the document workflow but does not allow this to be printed together with the document in view, I have therefore, attached screen shots to highlight that the letter was sent to the GP for perusal. I apologise for the fact that, at the inquest, I could not recall that the letter had been forwarded to me, as per protocol; I had not anticipated questions regarding this. 2. Adverse medication markers are not being placed on computerised medical records and this creates the risk that contraindicated medications may be inadvertently prescribed . We conducted an audit on Mr Hussain's medical records which showed that an alert was added to the records on 10/11/2020 alerting any clinician adding medication that may have potential misuse (including not to add benzodiazepines , opiates and gabapentin/pregabalin) and listing medication that could have an interaction with methadone. I attach an audit trail of this. This alert message appears as the patient record is accessed . However, to see further information within the record, this messaged must be closed to proceed further into the record. On the day of the inquest, I must have closed the alert, in order to proceed, therefore the message does not reappear unless a medication is to be added which would again trigger the alert to appear. This is the reason that, when questioned, it was not showing when you specifically asked about medication alert. I offer my apologies for this confusion on my part. I hope that the above provides reassurances that the previous Regulation 28 was actioned , and the changes made have been effective. Please accept my apologies again that this evidence was not provided at the inquest. I will be happy to provide further information, if asked to do so . Yours sincerely On behalf of my Partners who have reviewed and agreed on the word ing of this response.
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