Prevention of Future Deaths reports · 2024
Regulation 28 report to prevent future deaths, reference 2024-0002, written 2 Jan 2024. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 2 Jan 2024 |
|---|---|
| Reference | 2024-0002 |
| Deceased | Joy Ebanks |
| Coroner | Sean Cummings |
| Coroner area | Bedfordshire and Luton |
| Category | Alcohol, drug and medication related deaths |
| Organisation named | East London NHS Foundation Trust |
| 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 2 Kirby Road Surgery 1 CORONER I am Sean CUMMINGS, Assistant Coroner for the coroner area of Bedfordshire and Luton Coroner Service 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 14 June 2023 I commenced an investigation into the death of Joy EBANKS aged 59. The investigation concluded at the end of the inquest on 13 December 2023. The conclusion of the inquest was that: Mrs Joy Ebanks was discovered deceased on the 24th May 2023 at for pain. The medical cause of death was identified as due to oxycodone and pregabalin toxicity. . She was taking oxycodone and pregabalin as treatment 4 CIRCUMSTANCES OF THE DEATH Mrs Ebanks lived alone, she had been self neglecting and not engaging with support services. She suffered from Fibromyalgia, arthritis, agoraphobia. She had been diagnosed with depression and was prescribed both venlafaxine and quetiapine. She used cannabis. On the 24/05/2023, Mrs Ebanks was spoken to on the phone by her care worker at around 12:00 hours and asked for some tobacco to be bought to her during the visit. At around 16:00 hours, her care worker attended, got no response and so let herself in. She found Mrs Ebanks unresponsive, sitting up slumped to the side on the bed and contacted ambulance before attempting CPR. Paramedics attended but were unable to resuscitate her and she was pronounced deceased at the scene. There were previous expressions of suicide but she had not acted on them. Post mortem examination with toxicology gave the medical cause of death as: 1a Oxycodone toxicity enhanced by pregabalin intake 11 Bronchopneumonia, Coronary arteries atherosclerosis, Hepatic steatosis Mrs Ebanks had been prescribed opiates since at least 2009. Her medications at the time of death included long acting morphine - Longtec twice daily together with Pregabalin twice daily. She had been on this dose since at least 2014. There were periodic supplementations with Shortec 1-2 tablets up to four times daily (112 provided). The reason for the prescription was for fibromyalgia and "chronic pain" (undefined). Because of her agoraphobia and a dislike of people coming to her home, medication reviews were undertaken largely by telephone. There was evidence of poor communications between the agencies providing her with different aspects of her care. Regulation 28 – After Inquest Document Template Updated 30/07/2021 I was told that the practice had been addressing Prescription Drug Dependency and had utilised the Quality and Outcomes Framework Guidance for 2022/2023. Page 5 "Prescription Drug Dependency - Rationale" sets out some reasons for monitoring and rationalising prescription of dependency forming drugs thus: "Opioids are very valuable drugs for acute and palliative/end of life care but have a limited role in the management of chronic pain; for many patients they are not effective. Most prescribing is of short duration only; however, 3% of patients (CQC, 20202) with chronic pain receive continuing prescriptions for opioids for 3 years or more. Prolonged prescribing of these drugs may not be effective and is associated with dependence. Gabapentinoid prescribing has shown a 10 fold increase between 2000 and 2015 from 0.2% of patients in 2000 to 2.1% in 2015 (Cartagena et al. 2017),most of which has been off label and of unknown effectiveness; dependence on these drugs is increasingly recognised as a problem". There was evidence of attempts to review the medication prescribed but I remained unclear as to the purpose of the reviews. There was no evidence of any attempt to review the prescriptions of two dependency forming drugs with a view to reducing the dose over time. The opioid prescription was high. Mrs Ebanks was an agoraphobic lady with an ongoing mental health illness and what appears to be a iatrogenic drug dependency. 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) [1] There was evidence of very prolonged prescribing of two dependency forming drugs with no evidence to suggest that a discussion had been had or plan had been formulated to reduce the dosages. [2] The Guidance for Prescription Drug Dependency used by the practice highlights the hazards and limited utility of long term prescription of opioids for chronic pain. It also highlights the poor evidence base for use of gabapentinoids in these circumstances. [3] The primary cause of death was 1a Oxycodone toxicity enhanced by pregabalin intake. 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 February 27, 2024. 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:- Ms Ebanks NOK I have also sent it to :- East London NHS Foundation Trust 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 Regulation 28 – After Inquest Document Template Updated 30/07/2021 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: 02/01/2024 Sean CUMMINGS Assistant Coroner for Bedfordshire and Luton Coroner Service Regulation 28 (cid:177)(cid:3)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.
Practice Response to Regulation 28 Report to Prevent Future Deaths. To the Chief Coroner: We write in response to the Regulation 28 report dated 02.01.2024 from Sean Cummings, Assistant Coroner for Bedfordshire, and Luton Coroner Service. Mr Cummings commenced an investigation into the death of Mrs Joy Ebanks aged 59, which concluded on the 13 December 2023. The medical cause of death was identified as due to oxycodone and pregabalin toxicity. The Coroner found that the circumstances of death were as follows: Mrs Joy Ebanks lived alone, she had been self-neglecting and not engaging with support services. She suffered from Fibromyalgia, arthritis and agoraphobia. She had been diagnosed with depression and was prescribed both venlafaxine and quetiapine. She used cannabis. Mrs Ebanks had been prescribed opiates since 2009. Her medications at the time of death included long-acting morphine -Longtec 100mg twice daily together with Pregabalin 150mg twice daily. She had been on this dose since 2014. There were periodic supplementations with Shortec 5mg 1-2 tablets up to four times daily (112 provided). The reason for the prescription was for fibromyalgia and "chronic pain" (undefined). Because of her agoraphobia and a dislike of people coming to her home, medication reviews were undertaken largely by telephone. The Matters of Concern raised by the Coroner were as follows: 1. There was evidence of very prolonged prescribing of two dependency forming drugs with no evidence to suggest that a discussion had been had or plan had been formulated to reduce the dosages. 2. The Guidance for Prescription Drug Dependency used by the practice highlights the hazards and limited utility of long-term prescription of opioids for chronic pain. It also highlights the poor evidence base for use of gabapentinoids in these circumstances. 3. The primary cause of death was 1a Oxycodone toxicity enhanced by pregabalin intake. Kirby Road Surgery Response: Kirby Road Surgery are deeply saddened by the passing of Mrs Joy Ebanks and our sincerest condolences are with her family and friends. We are proactively utilising the learning opportunities that have arisen from these circumstances to deploy effective measures of improvement to mitigate future incidents and uphold patient safety. The practice promptly initiated an investigation and conducted a significant event analysis (SEA) to understand the root causes of the incident. For full information pertaining to our SEA (including the outcome of our root cause analysis), please see Appendix 1- Significant Event Analysis (SEA) Form. The Surgery also contacted Bedfordshire, Luton, and Milton Keynes Integrated Care Board (BLMK ICB) Medicines Management Team and Quality Team for advice and guidance, and to develop a robust approach to the issues which could then be presented for wider scale use across all Bedfordshire, Luton, and Milton Keynes (BLMK) practices. This will enable other BLMK practices to support their own work with patient cohorts, further promoting patient health, wellbeing, and safety on a wider scale. Kirby Road Surgery 58 Kirby Road, Dunstable, LU6 3JH 01582 609121 admin.kirbyroad@nhs.net This case was also discussed at organisational meetings which included: Quality Assurance Meetings, Clinical Team Meetings and Opioid Monitoring Meetings to share information, facilitate learning and enable staff to develop and deploy actions and improvement. For full details of these meetings, who they included and a summary of what was discussed, please refer to Appendix 2- Quality Improvement Monitoring Form. Our Clinical Lead Pharmacist identified, and risk scored all patients on opioid medications and also those on gabapentinoid medications to determine and recall individuals for a face-to-face structured medication review within a 28-day time period. These patients were then sent letters to inform them that their medication would be undergoing an upcoming review with a specialist prescribing pharmacist. These face-to-face structured medication reviews with our specialist prescribing pharmacist have already commenced, with a high patient uptake. Those patients who are housebound are receiving a home visit from the same specialist pharmacist. A structured medication review consists of: An assessment of the patients’ condition (s). A discussion to determine their experiences of pain and their pain scores. A review of their medication including when this was initiated and why. An exploration of what additional support may be required to promote good health and wellbeing, such as onward referrals to specialty services (including orthopaedic and pain management clinics) as well as mental health services. A structured plan being implemented so dose reduction can commence safely with 2 weekly follow up. Some patients would also require a review of their mental health support medication. Opioid prescribing agreement implemented with patient cooperation. All patients will undergo a follow up every 2 weeks with our specialist pharmacist. The Partners and Management Team sourced and recruited a specialist prescribing pharmacist (who has extensive experience of working in a pain clinic) to undertake the face-to-face structured medication reviews. Three of our inhouse clinical pharmacists are also undergoing training with our specialist prescribing pharmacist to enhance their skills and knowledge in this area to perform these reviews in the future. The Partners and Management Team sourced further training courses regarding opioid awareness, which has been approved by the BLMK Integrated Care Board (ICB). These courses include: ‘Reducing opioid prescribing for chronic pain’- introduces chronic pain, NICE guidelines, opioid efficacy with chronic pain and the adverse effects of opioids. ‘10-minute CBT for persistent pain’- involves training in effective skills for better supporting people with chronic pain in primary care. All clinical members of staff have undertaken these courses. For more details, please refer to Appendix 2- Quality Improvement Monitoring Form. Our Opioid Prescribing Policy and our Gabapentinoid Prescribing Policy underwent updating and review by the Quality Assurance Manager to ensure all information was up to date. This was further reviewed by BLMK Medicines Management Matthew Davies to ensure compliance. Once recommended actions were implemented into policy, this was then signed off and ratified by Kirby Road Surgery 58 Kirby Road, Dunstable, LU6 3JH 01582 609121 admin.kirbyroad@nhs.net members of staff in two clinical team meetings. For the Opioid Prescribing Policy, please see Appendix 3. For the Gabapentinoid Prescribing Policy, please see Appendix 4. Information from the updated Opioid Prescribing Policy and the Gabapentinoid Prescribing Policy has been uploaded onto the health hub section of our website, under the new section ‘High- risk medications.’ This section also provides information about medication dependency, their dangers, helplines patients can consult and helpful leaflets. The actions documented above reflect a commitment to learning from past events and continuously improving the quality of care provided to patients as well as our dedication to improving patient safety. We believe that the robust measures taken (as summarised above) will greatly enhance patient safety for those on high risk medications and continue our delivery of high quality and safe care. This case and action plan will be reviewed on the 11 March 2024 and again on the 15 April 2024. Kirby Road Surgery 58 Kirby Road, Dunstable, LU6 3JH 01582 609121 admin.kirbyroad@nhs.net
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