Prevention of Future Deaths reports · 2023
Regulation 28 report to prevent future deaths, reference 2023-0492, written 1 Sep 2023. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 1 Sep 2023 |
|---|---|
| Reference | 2023-0492 |
| Deceased | Stephen Ratclife |
| Coroner | Joanne Kearsley |
| Coroner area | Manchester North |
| 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 (1) REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: , Chief Executive Greater Manchester Integrated Care Partnership 1. Board CORONER I am Joanne Kearsley, Senior 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 the 20th February 2023, I commenced an investigation into the death of Stephen Ratclife, date of birth 6th October 1968 who died on the 6th February 2023 at his home address . The medical cause of his death was confirmed as 1a) Respiratory Depression due to 1 b) Combined Drug Toxicity 2) Developing Liver Cirrhosis and Anxiety and Depression. 4 CIRCUMSTANCES OF DEATH Stephen had a history of illicit drug and alcohol use. Had also had a diagnosis of depression and anxiety. He was under the local drug and alcohol services and for 11 months had been abstinent. He engaged well with his GP. In November 2022 he relapsed and in December 2022 was expressing suicidal thoughts. On the 10th January 2023 he collected his weekly methadone prescription. This was the last contact anyone is known to have had with Mr Ratcliffe until he was found deceased on the 6th February 2023. He had not collected his subsequent presciptions. During the course of the Inquest the court heard evidence that enquiries were also being made of his physical health in particular the need for him to have a blood test HBAc1 to check for diabetes. Due to difficult venous access these blood tests were not done. 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. The court heard that due to the deceased having compromised venous access as a result of his drug use, the GP practice were unable to take his bloods. The evidence before the court was that there is no specialist service for GPs to refer a patient to for bloods when venous access is difficult. Evidence was heard that this had been raised previously to the CCG. As a result, in this case no test for diabetes was obtained. w 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 26 October 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 namely:- The family of Mr Ratcliffe 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. 9 Date I.... 9- 1.0 2..1 - Sign~: ~ ~_/ - (9_,
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.
E: Quality.nhsgm@nhs.net Date: 01/12/2023 Ms J Kearsley HM Senior Coroner Coroner’s Court Greater Manchester North Dear Ms Kearsley Re: Regulation 28 Report to Prevent Future Deaths Thank you for your Regulation 28 Report dated 1st September October 2023 concerning the sad death of Stephen Ratcliffe on 6th February 2023. On behalf of NHS Greater Manchester Integrated Care (NHS GM), We would like to begin by offering our sincere condolences to Mr Ratcliffe’s family for their loss. Thank you for highlighting your concerns during Mr Ratcliffe’s Inquest which concluded on the 23rd of August 2023. On behalf of NHS GM, we apologise that you have had to bring these matters of concern to our attention. We recognise it is very important to ensure we make the necessary improvements to the quality and safety of future services. Following the inquest, you raised concerns in your Regulation 28 Report to NHS GM that there is a risk a future death will occur unless action is taken. The medical cause of death was 1a) Respiratory Depression due to 1b) Combined Drug Toxicity 2) Developing Liver Cirrhosis and Anxiety and Depression. I hope the response below demonstrates to you and Mr Ratcliffe’s family that NHS GM has taken the concerns you have raised seriously and will learn from this as a whole system. This letter addresses the issues that fall within the remit of NHS GM and how we can share the learning from this case. The court heard that due to the deceased having compromised venous access as a result of his drug use, the GP practice were unable to take his bloods. The evidence before the court was that there is no specialist service for GPs to refer a patient to for bloods when venous access is difficult. Evidence was heard that this had been raised previously to the CCG. As a result, in this case no test for diabetes was obtained. There are ten localities across the Greater Manchester system, each of these have commissioned phlebotomy services based on the communities they serve, this means that there are variations in service across the system. As this incident occurred in Bury, we have sought a response directly from this locality. There are a very small group of people who may be more difficult to take blood than others due to clinical presentation. Drug misusers are likely to be in this cohort. Bury Clinical Senate has reviewed this incident and a new pathway has been confirmed for Bury general 4th Floor, Piccadilly Place, Manchester M1 3BN Tel: 0161 6257791 www.gmintegratedcare.org.uk practices in relation to patients where venous access is difficult. Where venous access is difficult general practitioners (GPs) will be able to refer into the Same Day Emergency Care (SDEC) service. This new pathway will be promoted through targeted communications across Bury. To better understand the pathways across the other localities we will be developing a briefing, highlighting this event and using this to check and challenge what arrangements each locality has in place for access for patients where it is difficult to obtain blood. In addition to the locality-specific actions as set out above, a GM level review of phlebotomy provision has been undertaken recently which has identified the variation in provision and sets out the intention to improve the consistency of offer to patients across Greater Manchester. This is also a priority deliverable of the Greater Manchester Primary Care Blueprint. Actions taken or being taken to share learning across Greater Manchester: 1. Learning from the check and challenge exercise to be presented/shared with the Greater Manchester System Quality Group on the 18th of January 2024. This meeting is attended by commissioners, including commissioners of specialist services, localities, regulators, Healthwatch and NICE. Through sharing in this forum, we expect members to review and ensure learning is incorporated into their commissioned services. There will be a follow up review of implementation in July 2024. 2. Shared learning from this at Greater Manchester and borough level will be cascaded to professionals through relevant governance and learning forums to ensure that learning is incorporated into their services. In this case it will be discussed at the GM Primary Care Quality Group and the Long-term Condition Group in December. In conclusion, key learning points and recommendations will be monitored to ensure they are embedded within practice. NHS GM is committed to improving outcomes for the population of Greater Manchester. We hope this response demonstrates to you and Mr. Ratcliffe’s family that NHS GM has taken the concerns you have raised seriously and is committed to working together as a system including our service users, carers and families to improve the care provided. Thank you for bringing these important patient safety issues to our attention and please do not hesitate to contact me should you need any further information. Yours sincerely Mandy Philbin Chief Nursing Officer GM Integrated Care 4th Floor, Piccadilly Place, Manchester M1 3BN Tel: 0161 6257791 www.gmintegratedcare.org.uk
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