Prevention of Future Deaths reports · 2024
Regulation 28 report to prevent future deaths, reference 2024-0081, written 14 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 | 14 Feb 2024 |
|---|---|
| Reference | 2024-0081 |
| Deceased | Teresa Bennett |
| Coroner | Sarah Riley |
| Coroner area | North West Wales |
| Category | Alcohol, drug and medication related deaths · Wales prevention of future deaths reports (2019 onwards) |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
Assistant Coroner
for North West Wales
Sarah Olga Riley, Assistant Coroner for North West Wales
REGULATION 28 REPORT TO PREVENT FUTURE DEATHS
THIS REPORT IS BEING SENT TO:
Chief Executive of Betsi Cadwaladr University Health Board,
1
CORONER
I am Sarah Riley, Assistant Coroner for North West Wales
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.
http://www.legislation.gov.uk/ukpga/2009/25/schedule/5/paragraph/7
http://www.legislation.gov.uk/uksi/2013/1629/part/7/made
3
INVESTIGATION and INQUEST
On the 8th December 2021, I commenced an investigation into the death of Ms Teresa Ann
Bennett. The investigation concluded at the end of the inquest on the 9th February 2024.
CIRCUMSTANCES OF THE DEATH
4
Teresa Ann Bennett was a female, aged 57 at the time of her death. She had
a number of significant comorbidities, and her case was unusual and
complex. Mrs Bennett was prescribed and taking 13 separate medications at the time of
her death, seven of which, including Fentanyl, had side effects linked to the central
nervous system.
On the evening of the 30th November 2021, Ms Bennett’s son had seen her taking her
medication as usual. Ms Bennett retired to bed around 30 minutes or so later.
Around 3am on the 1st December 2021, Ms Bennett’s son found her asleep on the
bedroom floor, appearing to have fallen from the bed. He helped her back to bed,
ensuring she was comfortable, and left the room. At around 12pm on the 1st December
2021, Ms Bennett’s son noticed that she was still in bed and it became apparent that she
had passed away. Ms Bennett’s son called the Emergency Services who attended and
declared life extinct at 13.12pm.
A post mortem examination was ordered and the cause of death recorded at inquest was:
1a Multi organ failure
1b Fatty liver and combined drug toxicity
micrograms of Fentanyl over 72 hours. This was
Mrs Bennett was prescribed
patch and one
provided as one
identifiable as being different in size.
At post mortem,
Matrifen (a form of fentanyl) patches were found on Ms
Bennett’s legs, two on the left and one on the right. This would amount to a dose of
patch, both to be used at same time and
Coroner's Office, Shirehall Street, CAERNARFON, Gwynedd, LL55 1SH
. This dose differs from what was prescribed and issued by the GP and correlates
to a significant dose increase of
of morphine daily. The toxicological analysis showed multiple drugs with Fentanyl
being within the toxic and fatal range.
over 72 hours, which is the equivalent of
/ hr over 72 hours since 2008. The instructions recorded in
It was recognised that Ms Bennett was prescribed a high dose of Fentanyl. Ms Bennett
had been on a dose of
the GP notes simply stated ‘remove old patch and apply new patch every 72 hours’
There was no evidence to suggest that Ms Bennett was not compliant with her
medications. There was no evidence of ordering discrepancies, no stockpiling or using
the medication incorrectly and there was nothing to indicate that Ms Bennett raised any
concerns or mentioned any difficulties with the medication she was taking.
The prescription dose of Fentanyl had not changed since 2008 and the directions for use
had not changed. There was no evidence that the application of Fentanyl patches
resulting in a dose of micrograms was intentional. I found that Ms Bennett had
inadvertently overdosed on Fentanyl, and that, in combination with other medicines, a
number of which possessed the ability to depress the nervous system, led to her death.
Ms Benett’s GP practice was managed directly by the Health Board. It is Standard
Health Board practice for medication reviews to be completed at 12-15 month intervals
but, in Ms Bennett’s case, that target had not been met on a single occasion since 2015.
There is a lack of monitoring and no standardised process for medication reviews in the
Health Board managed practices.
There is a risk of harm if medication reviews are not undertaken at regular intervals,
including a risk of death in complex cases, like Ms Bennett’s. There is also a risk of
harm or death if all pertinent matters are not considered during the reviews. At inquest,
the Health Board produced an improvement plan that, inter alia, included actions to
address the lack of compliance with the 12-15 monthly medication reviews. The target
completion date for addressing the lack of compliance with the 12-15 monthly
medication reviews is the 31st May 2025, a further 15 months from now. This, in my
view, is not quick enough and I am concerned that future deaths may occur.
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) Lack of compliance with the target of 12-15 monthly medication reviews in Health Board
managed GP practices.
(2) No standard practice for medication reviews leading to a lack assurance that all pertinent
matters will be covered and the approach varying between clinicians and practices.
(3) The risk of inadvertent overdose in individuals like Ms Bennett, where medication that
can cause e.g drowsiness and fatigue, is prescribed alongside strong opiates and other
drugs that have the ability to depress the central nervous system when such medicines
are prescribed without regular reviews nor specific advice in respect of the associated
risks issued to patients e.g in Ms Bennett’s case, she was instructed to simply “remove
old patch and apply new patch every 72 hours”
Coroner's Office, Shirehall Street, CAERNARFON, Gwynedd, LL55 1SH
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
10th April 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 Ms Bennett’s son, as an Interested
Person
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.
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 14th February 2024
Signature_________________________
Assistant Coroner for North West Wales
Coroner's Office, Shirehall Street, CAERNARFON, Gwynedd, LL55 1SH
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.
Bloc 5, Llys Carlton, Parc Busnes Llanelwy, Llanelwy, LL17 0JG ---------------------------------- Block 5, Carlton Court, St Asaph Business Park, St Asaph, LL17 0JG Dyddiad / Date: 10 April 2024 Sarah Riley HM Assistant Coroner North Wales (West) Coroner's Office Coroner's Office Shirehall Street CAERNARFON Gwynedd, LL55 1SH Dear Ms Riley, REGULATION 28 REPORT TO PREVENT FUTURE DEATHS Teresa Ann Bennett I write in response to the Regulation 28 Report to Prevent Future Deaths dated 14 February 2024, issued by yourself to Betsi Cadwaladr University Health Board, following the inquest into the death of Teresa Ann Bennett. I would like to begin by offering my deepest condolences to the family and friends of Ms Bennett. In the notice, you highlighted your concerns regarding: The lack of compliance with the target of 12-15 monthly medication reviews in Health Board managed GP practices; The absence of a standard practice for medication reviews leading to a lack assurance that all pertinent matters will be covered and the approach varying between clinicians and practices; The risk of inadvertent overdose in individuals like Ms Bennett, where medication that can cause e.g. drowsiness and fatigue, is prescribed alongside strong opiates and other drugs that have the ability to depress the central nervous system when such medicines are prescribed without regular reviews nor specific advice in respect of the associated risks issued to patients. In response to these concerns, I asked our primary care teams to review and submit improvement actions which are detailed below. We have commenced benchmarking work on 21 February 2024 for all Health Board managed practices to identify all patients on regular repeat medication who have not got a medication review documented in the notes in the last 12-15 months. This work will be completed by 31 May 2024. These patients will then be risk stratified for medication review. This will occur parallel to implementing new procedures as outlined below. Cyfeiriad Gohebiaeth ar gyfer y Cadeirydd a'r Prif Weithredwr / Correspondence address for Chairman and Chief Executive: Swyddfa'r Gweithredwyr / Executives’ Office Ysbyty Gwynedd, Penrhosgarnedd Bangor, Gwynedd LL57 2PW Gwefan: www.pbc.cymru.nhs.uk / Web: www.bcu.wales.nhs.uk A pan Health Board policy is now being developed to outline the standards for medication review within our managed practices. This will be completed by 30 June 2024. In order to ensure we review outstanding patients on repeat medication the policy will risk score patients on a priority level from 1 to 4 and outline exactly who will be included in each level. For example, Level 1 risk patients will be those >75 on polypharmacy, patients on high dose opiates, down to level 4 patients who are under 50 and on less than 4 medications. Standard Operating Procedures will then be put in place at each practice to add the detail of responsibility and governance of the process; this will differ at each practice due to staffing skill mix. Practices will report their progress against medication review targets at assurance meetings that will be held regularly (every 2 months). These will be reported at a newly formed managed practice Quality and Governance Group which will cover all North Wales services. Addressing the concerns regards patient information and their awareness of risks, additional warnings are included on pharmacy labels on the outside of medication boxes, which reference the risks of drowsiness. In addition, patient information leaflets are included in every box which outlines what to do in various scenarios e.g., increased drowsiness, if patches no longer giving pain relief, and if a patch falls off. Health Board Managed Practices will, from 01 May 2024, add the Faculty of Pain Medicine opioid leaflet onto the clinical system. This will be printed and given to patients on opioids at their medication review, or when opioids are started or doses changed. A copy of this leaflet is attached as an appendix. Learning will be shared with independent contractor GP practices via the primary care governance processes. Our medicines management Local Enhanced Service (LES) running from April 2024 - March 2025 will contain two sections on opioid prescribing. This LES is applicable for all GP practices within the Health Board area and is mandatory. We would be happy to meet with you further and discuss our plans in more detail, or provide further information and assurance should that be helpful. Once again, I offer my deepest condolences to the family and friends of Ms Bennett for their loss and I reiterate my sincere apologies to them for the concerns identified at inquest. Yours sincerely Cyfarwyddwr Meddygol Gweithredol / Dirprwy Prif Weithredwr Dros Dro Executive Medical Director / Acting Deputy Chief Executive cc , Deputy Executive Medical Director , Deputy Director of Quality
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