Prevention of Future Deaths reports · 2017
Regulation 28 report to prevent future deaths, reference 2024-0220, written 27 Feb 2017. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 27 Feb 2017 |
|---|---|
| Reference | 2024-0220 |
| Deceased | Rachel Edwards |
| Coroner | Nigel Parsley |
| Coroner area | Suffolk |
| Category | Alcohol, drug and medication related deaths |
| Organisation named | Norfolk and Suffolk 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 ( 1) REGULATION 28 REPORT TO PREVENT FUTURE OEATHS THIS REPORT IS BEING SENT TO: , Chief Executive, Norfolk and Suffolk NHS Foundation Trust, 1 CORONER I am Nigel Parsley, Area Coroner, for the coroner area of Suffolk, 2 CORONER'S LEGAL POWERS I make this report under paragraph 7, Schedule 6, of the Coroners and Justice Act 2009 and Regulations 28 and 29 of the Coroners (Investigations) Regulations 2013, 3 INVESTIGATION and INQUEST On 151h May 2017 I commenced an investigation into the death of Rachel Holly Edwards. The lnvesffgation concluded at the end of the Inquest on 221><l February 2018, The conclusion of the Inquest was that Rachel Edwards died as the result of an overdose of her prescription medicines following a seven-year period of suffering from severe and unbearable pain, the result of injuries sustained in a fall from height in 2009. The medical cause of death was confirmed as: 1(a) Over dose of multiple drugs. 4 CIRCUMSTANCES OF THE DEATH Rachel died on the 8th May 2017as the result of an over dose of multiple prescription medicines at her home address , Suffolk. A concerned friend had been unable to contact her when visiting Rachel's home and had called her family. Rachel's father Chris arrived al a short while later with a spare key to the property, entered and subsequently found his daughter fully clothed but unresponsive in the bath. The emergency services were called and upon arrival of a paramedic Rachel's death was recognised at 08.39 on the 81h May 2017. 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 could occur unless action is taken. In the circumstances it is my statutoiy duty to report to you; the MATTERS OF CONCERN as follows:- Prior lo Rachel's death, on the 61h March 2017 she was informally admitted to the Woodlands mental health ward In Ipswich following a significant overdose she had taken on the 3"' March 2017. I I I I I Rachel told the admitting doctor that the overdose consisted of types of medication taken impulsively due to ongoing pain, lack of sleep and being discharged from a pain clinic that had offered hope of a trial surgical implant to manage her pain. tablets of various It is clear from the evidence presented that Rachel's low mood and feeling of 'hopelessness' was directly linked to the constant pain she was suffering. Witnesses also described that Rachel's low mood and feelings of hopelessness were compounded when she received negative news regarding her pain management This was not isolated to the incident noted above but was a feature of Rachel's presentation known by her family, care co-ordinator and treating mental health care professionals. Rachel was discharged from Woodlands on the 29th March 2017. Evidence was put forward regarding Rachel's (and her family's) belief she was being discharged too soon and would not be safe at home. This evidence was considered in depth and based on that evidence Rachel's actual discharge date is not the subject of this report to prevent future deaths. However, two issues of concern surrounding Rachel's discharge and her subsequent treatment in the community were identified during the inquest The first concern regards the prescription of discharge medication, sharing that information with the GP and record keeping. It was known that Rachel was at risk of stockpiling medication as in the Serious Incident Requiring Investigation (SIRI) report it is noted that a request made on the 7th March 2017 by her treating doctor, for the disposal of her stocks of medication had not been actioned. Further, Rachel's care co-ordinator specifically recalled asking Rachel if she had stockpiled any medication after her discharge on the 29th March 2017, as he had identified this to be a risk. It is therefore a concern that according to Rachel's notes that on the day of her discharge she was supplied with 14 days of medication. This was described in evidence as 'standard practice'. That said, some consideration appears to have been given to the quantity of some medication issued, as on closer inspection of the notes it was identified that specifically in relation to Tramadol Rachel had been prescribed this for only a 7-day period. However, there was no clear record within the notes if her other medication had actually been issued in 7 or 14 days amounts. Such confusion over the actual quantities of medication Issued and the apparent issuing of 14 days supply of medicines to a patient who is known to have previously stockpiled medication, with a view to self-harm, is of obvious concern. Also of concern was evidence given by a senior consultant that there is no automated notification to a patient's GP of the type and amounts of prescription medicines issued to a patient upon discharge from Woodlands. Obviously, it is crucial that this information is readily available to a GP in all cases, to ensure that the over- prescription of medicines to a recently discharged patient does not occur. Evidence was heard that in order for Woodlands to notify a GP it is necessary for a staff member to e-mail the relevant practice, providing details of the prescriptions that had been made. This Information would then have to be subsequently included in the patient's local record before It was available to the treatina GP. Obviouslv. anv svstem requiring such physical human input can be prone to failure and in the consultant's own words it was a recognised 'point of weakness in the system' Secondly, it was a known that the arrival of disappointing news regarding her pain management treatment was a clear stressor to Rachel and that such news significantly increased her sense of hopelessness. Despite this being known there was no 'patient advocate' or other similar service in place to act as filter and alert those providing support to prepare for the increased feeling of hopelessness that would clearly follow such news. Further, dealing with the large quantity of correspondence generated by her various treatment regimes and trying to de-conflict and re-schedule multiple appointments also left Rachel feeling overwhelmed, again adding to her sense of hopelessness. Again, no effective patient advocate system was in place to support her with this. During the inquest an example of the good use of a 'patient advocate' scheme was heard, but this advocate was in place by virtue of the initiative of a local mental health practitioner. As such it was identified that although a 'patient advocate' could provide the support needed when appropriate, there is no formal system in place for an advocate to be appointed in other cases when it could prove beneficial. 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you 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 24th April 2018. I, the Area Coroner, may extend the period if I consider it reasonable to do so. 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 Person, I am under a duty to send the Chief Coroner a copy of yo.ur 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 Area Coroner, at the time of your response, about the release or the publication of your response by the Chief Coroner. 9 27th February 2017 Nigel Parsley
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.
2 7 APR 2018 r~1:k1 Norfolk and Suffolk NHS Foundation Trust Trust Management 1st Floor Admin Hellesdon Hospital Drayton High Road Hellesdon Norwich NR6 5BE 23 April 2018 Private and Confidential Mr Nigel Parsley HM Area Coroner for Suffolk The Suffolk Coroner's Service Beacon House White House Road Ipswich Suffolk IP1 5PB Dear Mr Parsley Re: Regulation 28 report following the inquest of Ms Rachel Edwards I write in response to your report dated 27 February 2018. Under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013 you requested the Trust consider issues of service delivery following the conclusion of the inquest into the sad death of Ms Edwards. I will address the matters you raised in the order received: Medication on discharge from hospital You raised the matter that Ms Edwards had a known risk of stockpiling medication. Despite this risk she was discharged from hospital with 14 days of medication, referred to at the inquest as standard practice. You explained further examination identified that the prescription for Tramadol was given for seven days indicating there had been some assessment of risk. The records were not clear what numbers had been given for each medication. You were concerned that individual consideration of the service user's needs and risks may not be consistent. Discharge from hospital is a known period of opportunity and risk for services users. It can represent a sign of the individual's recovery whilst also presenting new challenges. Each service user's journey through this period is different and requires a responsive individualised approach from the care team. The Trust will make an assessment of the medications prescribed upon discharge and this consideration will continue across the Trust. In the majority of situations an individual's recovery into the community is supported by a period of care with the Crisis Resolution and Home Treatment team. Separate but linked, the Trust has completed some exploratory work on examining deaths of our service users where prescribed medication is listed within the cause of death. This has shown that opioid medication has the highest prevalence, matching the national picture. The Trust supports the work of Public Health England and the Faculty of Pain Medicine in raising awareness of opioids , their benefits and uses, but also the risks associated with them. The Trust has raised the learning of the prevalence of opioids as a cause of death with its staff through its safety together newsletter and is completing a further thematic review of the deaths, in order to identify what additional learning may be made. This is being presented to the Trust's Mortality Review Group in May 2018. ~,•1..Working together =~t- for better mental health Trust Headquarters: Hellesdon Hospital, Drayton High Road , Norwich NR6 5BE Notification to GPs of the prescribed medication upon discharge You raised the matter that there was no automated notification to the service user's GP of the type and amounts of prescribed medication issued at the point of discharge. This information is crucial to help reduce the potential of over prescribing. You heard that the current process involves human action through use of emails. There is a national programme looking to build these electronic bridges between different elements of the health system. Locally, the Trust is planning the technical changes required. At this time, there is no confirmed date for completion of this work. I would be pleased to update you on progress over time. Advocacy Your third point raised the matter that Ms Edwards' situation was heavily influenced by the physical pain she experienced. She received disappointing news regarding her pain management treatment, increasing her sense of hopelessness. You heard evidence that she did not have an advocate to support her. You stated that advocacy services provide support to people in need and that we should consider establishing a formal system for an advocate to be appointed, where this may be beneficial. The Trust supports the significant and valuable role that advocacy services provide. The Trust is established in working with advocacy services as part of statutory frameworks, such as the Mental Health Act, Mental Capacity Act and complaints regulations. Equally, the Trust works with advocacy services where this has been requested by the service user to support the best possible forms of communication and collaboration. Such services are not commissioned by the Trust and the process to access such are either through service user consent or under the guidance of the above named frameworks. The Trust will register this matter with its commissioners. Thank you for raising these matters. If I can be of any further assistance please do not hesitate to contact me. Yours sincerely Chief Executive ~:-•-_4) Working together =f'~""' for better mental health Trust Headquarters: Hellesdon Hospital, Drayton High Road, Norwich NR6 5BE www.nsft.nhs.uk
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