Prevention of Future Deaths reports · 2024
Regulation 28 report to prevent future deaths, reference 2024-0137, written 13 Mar 2024. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 13 Mar 2024 |
|---|---|
| Reference | 2024-0137 |
| Deceased | Jane Walker |
| Coroner | Kate Robertson |
| Coroner area | North West Wales |
| Category | Other related deaths · 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.
Kate Robertson Senior Coroner for North West Wales REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: The Rt Honourable James Cleverly, Secretary of State for the Home Office 1 CORONER I am Kate Robertson, HM Senior 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. 3 INVESTIGATION and INQUEST On 11 August 2020 an investigation was commenced into the death of Jane Walker (DOB 3 April 1968) who died on 8 August 2020. The investigation concluded at the end of the inquest on 13 March 2024. The conclusion of the inquest was accident. 4 CIRCUMSTANCES OF THE DEATH The circumstances of the death are as follows :- On 8 August 2020 Jane Walker was a passenger on a rigid inflatable boat on the Menai Straits when a collision occurred between the rigid inflatable boat and a jet ski. Jane suffered significant internal injuries, was attended to by paramedics at the slip way and then conveyed to hospital, where she later died. The circumstances were investigated by the Marine Accident Investigation Branch. 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 – Coroner's Office, Shirehall Street, Caernarfon Jane was administered morphine for pain relief at the slip way by the paramedics. Administering such opioid medication takes time in that a cannula must first be inserted and once administered the morphine can take up to 15 minutes to be effective. Evidence was heard at the Inquest that there are alternative analgesics which can be administered much more quickly, have a much quicker impact and can be easier to remove when required. Example of such is mucosal fentanyl lozenge. This can be administered by placing the lozenge (on a stick) into the patient’s mouth, which takes effect very quickly and which can be removed quickly if required. It can be considered a safe and rapid method of delivering pre-hospital analgesia and is used by the military. It is not, however, available to paramedics. I am concerned that the unavailability of such analgesics to paramedics (in England as well as Wales) to assist patients who require immediate pain relief in the context of it reducing stress on the body, providing easier and potentially faster extrication and patient handling, and improving breathing, where time is of the essence for medical treatment, to reflect a risk of deaths into the future. Pursuant to controlled drug legislation paramedics are not currently permitted to administer such analgesics. Whilst matters of health are devolved to Wales, controlled drug legislation in this context is not a devolved matter to Wales, hence this Report to the Home Secretary. I am aware that The Medicines Act 1968 and/or other controlled drug legislation would require amendment to allow paramedics to administer such analgesia. 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you 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 8 May 2024. I, Kate Robertson, 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 Family of the Deceased and to the Chief Coroner. I have also sent a copy of this Report to the Chief Executive of the Welsh Ambulance Service Trust for his information. 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 Coroner's Office, Shirehall Street, Caernarfon your response, about the release or the publication of your response by the Chief Coroner. 9 Dated 13 March 2023 Signature Kate Robertson HM Senior Coroner for North West Wales Coroner's Office, Shirehall Street, Caernarfon
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.
Official-Sensitive Kate Robertson HM Senior Coroner for North West Wales HM Coroner’s Office, Shirehall Street, Caernarfon, Gwynedd LL55 1SH 01286 672804 Dear Ms Robertson Thank you for your Prevention of Future Deaths report of 13 March concerning the tragic death of Jane Walker who died after a collision with a jet ski while on a rigid inflatable boat. In the report you recommend that paramedics should be provided with powers to administer mucosal fentanyl lozenges to ensure fast acting pain relief. You are receiving a response from an official in accordance with procedures for handling correspondence during the pre-election period. I understand that evidence heard at the inquest included detail about a mucosal fentanyl lozenge as an alternative, easier to remove and faster-acting analgesic to that received by Ms Walker (who was administered morphine via a cannula, which can take 15 minutes to be effective). At the time of Ms Walker’s death paramedics did not have the authority to administer that form of pain relief. Your recommendation mirrors two recommendations made in the report Manchester Arena Inquiry Volume 2: Emergency Response, which are as follows: Recommendation 118: The Department of Health and Social Care and the Medicines and Healthcare products Regulatory Agency (MHRA) should consider urgently whether the regulatory regime should be altered to enable analgesia, such as fentanyl lozenges or sufentanil sublingual tablets, to be given by paramedics to injured persons. Recommendation 119: If the decision is that the regulatory regime should be altered in this way, the National Ambulance Resilience Unit should consider urgently whether the use of such analgesia should be rolled out to all Hazardous Area Response Team and other specialist operatives, as part of their basic equipment, and to paramedics more generally. The Manchester Arena Inquiry reports are available at the following link: Manchester Arena Inquiry reports - GOV.UK (www.gov.uk) Official-Sensitive The NHS England Task & Finish Group on Analgesia was established to consider these two recommendations. This comprises civilian and military clinical representatives, academics, representatives of the Faculty of Pre-Hospital Care, the College of Paramedics, ambulance pharmacists and government officials. This group works closely with colleagues in the Devolved Administrations to ensure any learning is shared and can be considered for use in the respective countries. Evidence gathering and evaluation are ongoing. The group has been provided with a copy of your letter for their reference. Once this group has reported its conclusions, these and any recommendations about paramedics and the administration of fentanyl will be considered by a future government. Yours sincerely Head of Drug Misuse Unit
See every Prevention of Future Deaths report matching Alcohol, drug and medication related deaths, and how often a new one appears.
What would an alert for this have sent me? Search the full text
Free to try — the preview shows the real matches and how many arrived in the last 12 months. Your first email alert is free.
These reports are published by the Chief Coroner's office at judiciary.uk and are © Crown copyright. The text here is reproduced from the published PDF so it can be searched. If something on this page is wrong, or you are a person named in it and want it reviewed, email drcjar@gmail.com and we will act promptly.