Prevention of Future Deaths reports · 2024
Regulation 28 report to prevent future deaths, reference 2024-0070, written 8 Feb 2024. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 8 Feb 2024 |
|---|---|
| Reference | 2024-0070 |
| Deceased | Dayle Bates |
| Coroner | Robert Cohen |
| Coroner area | Cumbria |
| 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.
Kally Cheema LLB | Senior Coroner | Cumbria
Fairfield, Station Road, Cockermouth, Cumbria CA13 9PT
8 February 2024
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REGULATION 28 REPORT TO PREVENT FUTURE DEATHS
THIS REPORT IS BEING SENT TO: Recovery Steps Cumbria
CORONER
I am Robert Cohen HM Assistant Coroner for Cumbria
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.
http://www.legislation.gov.uk/ukpga/2009/25/schedule/5/paragraph/7
http://www.legislation.gov.uk/uksi/2013/1629/part/7/made
INVESTIGATION and INQUEST
On 8 September 2023 I commenced an investigation into the death of Dayle BATES. The
investigation concluded at the end of the inquest . The conclusion of the inquest was
Drug related death.
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1a Drug Intoxication
1b
1c
II
CIRCUMSTANCES OF THE DEATH
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Dayle Bates was 39 years old. He lived in Workington, Cumbria. Mr Bates had a past
medical history of drug misuse. On 31st August 2023 Mr Bates' body was discovered at
his home. Ambulance staff were unable to revive Mr Bates and his death was confirmed
at 11:50. A post mortem examination has confirmed that his death was caused by the
combined effect of heroin, bromazolam, protonitazene, xylazine and alcohol.
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) Mr Bates had a prescription for methadone issued by Recovery Steps. He was
required to collect a dose each day from a named pharmacy. On 14th July 2023 Mr Bates
stopped collecting methadone. The pharmacy explained that they sought to inform
Recovery Steps of this development shortly after 14th but did not have any contact details
other than a general number which is not always answered and a direct line for one key
worker. They attempted to raise their concerns with that key worker, but the message
appears not to have been relayed. Recovery Steps did not become aware that Mr Bate
was not collecting methadone until 30th August 2023.
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In answer to question from the Court, the pharmacy have also indicated that although it is
there practice to inform Recovery Steps of any other concerns they might have about a
person prescribed with methadone, this is a voluntary decision on their part and not a
matter that arises from any obligation.
I am concerned that this situation gives rise to a risk of future death. It appears that there
is no direct means by which a pharmacy can report to Recovery Steps that a service user
has stopped collecting methadone. There is also no apparent obligation on pharmacies to
report wider concerns for service users' welfare to Recovery Steps. In each case this may
mean that Recovery Steps are unaware that vulnerable service users require additional
support.
ACTION SHOULD BE TAKEN
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In my opinion action should be taken to prevent future deaths and I believe you Recovery
Steps Cumbria have the power to take such action.
YOUR RESPONSE
You are under a duty to respond to this report within 56 days of the date of this report,
namely by 5th April 2024. I, the coroner, may extend the period.
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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.
COPIES and PUBLICATION
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I have sent a copy of my report to the Chief Coroner and to the following Interested
Persons: the family of Mr Bates.
I have also sent it to
of J H Sandham Chemists, who may find it useful
or of interest.
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
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.
8 February 2024
9
Signature
Robert Cohen HM Assistant Coroner for
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.
Recovery Steps Cumbria
Stocklund House
Castle Street
Carlisle
CA3 8SY
Coroner’s Office
Fairfield
Station Road
Cockermouth
CA13 9PT
22nd March 2024
Dear Mr Cohen
Re: Humankinds response in regard to the Regulation 28, following the Inquest into
the late Dayle Bates
Following on from your letter dated 8th February 2024, which outlined the matters of concern
identified during the coronial process, as the Area Manager of the addictions services within
Cumbria I would like to detail a response to the particular concerns you have raised.
It is stated within your findings that Recovery Steps Cumbria issued Mr Bates with a
methadone prescription, to clarify Mr Bates’ care was managed under Shared Care, which
means that he was provided with Opioid Substitute Treatment (OST) via his General
Practitioner, with Recovery Steps Cumbria working in partnership with the GP to deliver
psychosocial interventions. In this instance the prescriber was from James St Surgery in
Workington, and it is the GP surgery who owns the prescription and is responsible for the
management of medication in Mr Bates’ case.
With regards to the comments made by the Community Pharmacy, they are inaccurate.
There is a duty upon Pharmacists with regards to liaison with prescribers for controlled
medication as set out in their Medicines, Ethics and Practice Guidance (MEP). The actual
wording from the MEP Guidance is: “If you know a patient has missed three days’ prescribed
treatment (or the number of days defined by any local agreement with the prescriber), there
is a risk that they will have lost tolerance to the drug and the usual dose may cause
overdose. In the best interests of the patient, consider contacting the prescriber to discuss
appropriate next steps.” MEP Section 3.6.7 Prescription requirements for Schedule 2 and 3
Controlled Drugs.
Recovery Steps Cumbria is a service led by Humankind. Humankind is a company registered in England. Registered Company No1820492 and a
Registered Charity No. 515755. VAT No 334676343.Registered Social Landlord (RSL) 4713Registered Office: Inspiration House, Unit 22 Bowburn North
Industrial Estate DH6 5PF
Although in this instance the prescription wasn’t managed by Recovery Steps Cumbria, as a
point of further assurance in regard to how Humankind manages communication with
Community Pharmacies, all prescriptions generated by Recovery Steps Cumbria has official
Home Office approved wording on them which states "Please dispense instalments due on
pharmacy closed days on a prior suitable day. If a collection has been missed, please
dispense the amount due for remaining day(s). Consult a prescriber if 3 or more consecutive
days have been missed. Dispense daily doses in separate containers”.
As of January 2024, The Office for Health Improvement and Disparities has published new
guidance for Community Pharmacies delivering substance misuse services, under the
management of missed doses section, guidance clearly states “If a person misses 3
consecutive doses (or any doses during titration) for an opioid substitute, the pharmacist
should put the prescription ‘on hold’. The pharmacist (or another designated pharmacy staff
member) should then contact the prescriber to discuss if it’s suitable to continue to supply
the opioid substitute. If they cannot contact the prescriber (for example when working out of
hours), the person may be refused one or more doses. The pharmacist should record all
refusals (with associated rationale) on the person’s PMR and on the prescription, and they
should tell the prescriber as soon as possible”. While the publication date for this was after
the date of this case, it is clear from the MEP guidance and “best practice” in supporting
patients prescribed OST that pharmacists contact the prescriber i.e., the Shared Care GP, if
a patient has failed to collect 3-days consecutive OST medication.
Humankind has Service Level Agreement’s (SLA’s) in place with Community Pharmacies
who deliver Supervised Consumption and Needle and Syringe provision on behalf of the
service. Humankind also has SLA’s in place with all GP surgeries who deliver Shared Care.
In all SLA’s there is clear guidance with regards to the roles and responsibilities of each
party. A copy of the current SLA for Community Pharmacies delivering OST supervised
consumption services has been attached for your information. For point of clarity, Mr Bates
was not on supervised consumption at the time of his death, however, it was felt appropriate
to share the content of the SLA to demonstrate the duty placed on parties in regard to the
appropriate management of cases, in particular those cases where consecutive missed
doses occur.
In response to the concerns raised regarding the difficulty the Community Pharmacy
experienced contacting the service, Humankind has completed an in-depth reviewal of the
clinical system the service uses, to establish any recorded activity contained within Mr Bates
case file or in reference to Mr Bates’s treatment during the time period when Mr Bates
stopped collecting his medication until the time Recovery Steps Cumbria were notified of his
death. No activity was found during this time period. In addition, phone data was requested
from the telephone provider to enable call analysis to be conducted, however, only 6 months’
worth of historical data can be accessed which didn’t cover the time period being reviewed.
Although Recovery Steps has found no evidence that a call was received, or that a named
worker was contacted by the Community Pharmacy, the service has communicated with all
staff the importance of accurate record keeping and information sharing following all phone
calls received. This has also been included in Recovery Steps Cumbria’s record keeping
training.
Recovery Steps Cumbria has 2 predominant contact methods that are used by partners and
individuals seeking support, the first being via telephone, where one phone number is used
Recovery Steps Cumbria is a service led by Humankind. Humankind is a company registered in England. Registered Company No1820492 and a
Registered Charity No. 515755. VAT No 334676343.Registered Social Landlord (RSL) 4713Registered Office: Inspiration House, Unit 22 Bowburn North
Industrial Estate DH6 5PF
to cover all sites within Cumbria, we have a dedicated team of Administrators who answer all
incoming calls during opening hours. Humankind does acknowledge that at times phone
lines are busy, which can mean a delay in getting through to an Administrator. The second
general contact method is via email, the service has a referral email address and an
additional secure email address, which is predominantly used by partner agencies, both
email accounts are monitored daily.
For assurance, in light of your findings, Humankind has undertaken a targeted piece of work
to address and reduce risk in the hope that future deaths are prevented, this work includes:
• That all Community Pharmacies have correct contact information for Recovery Steps
Cumbria, including phone numbers and secure email addresses.
• That all Community Pharmacies are aware of the obligations on them when it comes
to dispensing Opioid Substitution Treatment.
• Communication has been had with both the North and South Cumbria
Pharmaceutical Committees.
• That the medicines optimisation leads from both North and South Cumbria’s
Integrated Care Boards are informed of the issue that has been highlighted and that
there is a co-ordinated approach to services delivered to the people in Cumbria.
• Communication had with all Shared Care services, to ascertain if approved Home
Office wording is detailed on all prescriptions generated, if not, for them to ensure it is
added moving forward.
I hope that the above offers reassurance in respect of how Humankind has responded to the
issues you have raised. Reducing drug and alcohol related deaths within the county is a
priority for Humankind, and we are committed to working collaboratively with all partner
agencies to learn from and reduce the number of deaths in the area.
Yours sincerely
Area Manager
Recovery Steps Cumbria is a service led by Humankind. Humankind is a company registered in England. Registered Company No1820492 and a
Registered Charity No. 515755. VAT No 334676343.Registered Social Landlord (RSL) 4713Registered Office: Inspiration House, Unit 22 Bowburn North
Industrial Estate DH6 5PF
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