Prevention of Future Deaths reports · 2024
Regulation 28 report to prevent future deaths, reference 2024-0271, written 17 May 2024. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 17 May 2024 |
|---|---|
| Reference | 2024-0271 |
| Deceased | Jonathan Szczepanski |
| Coroner | Jayne Wilkes |
| Coroner area | Lincolnshire |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| Organisation named | United Lincolnshire Teaching Hospitals NHS 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. Lincolnshire Integrated Care Board CORONER I am Jayne Wilkes, Area Coroner for the Coroner Area of Greater Lincolnshire 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 31 May 2023 I commenced an investigation into the death of Jonathan Paul SZCZEPANSKI aged 64. The investigation concluded at the end of the inquest on Monday 13 May 2024. The conclusion of the inquest was: Medical cause of death: 1(a) Upper Gastrointestinal Haemorrhage 1(b) Duodenal Ulcer 2 Naproxen Treatment Conclusion Mr Jonathan Paul Szczepanski died from the consequence of a duodenal ulcer to which the prescription of Naproxen without the corresponding Protein Pump Inhibitor (PPI) made a contribution. 4 CIRCUMSTANCES OF THE DEATH (1) (2) (3) (4) (5) (6) (7) Mr Jonathan Paul Szczepanski had a significant medical history which included Parkinson's Disease, Type 2 Diabetes, Hypertension and Spinal Stenosis. He had several repeat prescriptions from his GP surgery to treat his conditions and to provide pain relief. This included Naproxen, a non-steroid anti-inflammatory drug (NSAID) which had been prescribed regularly since 2016 on a dosage level of 500mg twice daily. No corresponding proton pump inhibitor (PPI) medication had ever been prescribed to address the recognised risk of duodenal ulceration from NSAIDs. No medication reviews had taken place to address or manage the risks of long term NSAID prescription, against the background of his relevant co-morbidities. He was admitted to Boston Pilgrim Hospital on 28 April 2024 with an acute kidney injury due to suspected infection and urinary retention. He was discharged on 2 May 2024 with a repeat prescription of Naproxen - 500mg twice daily. No PPI medication was prescribed. He was admitted to Boston Hospital on 14 May 2023 with symptoms indicative of a gastrointestinal bleed. Despite repeated medical and surgical intervention, he did not respond to treatment and his condition was such that further intervention was not possible. He was placed on end-of-life care until he passed away. Regulation 28 – After Inquest Document Template Updated 30/07/2021 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 statutory duty to report to you. The MATTERS OF CONCERN are as follows: (1) (2) (3) There is a lack of local practitioner guidance on the practical implementation of the NICE NSAIDs - prescribing issues documentation. The software being used to prescribe NSAIDs did not automatically generate a specific warning flag to alert the prescriber to the considerations and risk factors in the prescription of NSAIDs (including the use of PPI). Where repeat prescriptions were issued on discharge of a patient from hospital back to community primary care, there was no warning on the discharge documentation to alert the prescriber to the considerations and risk factors in the prescription of NSAIDs (including the use of PPI). 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe 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 July 12, 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: (1) , Welby Group, The New Coningsby Surgery, 20 Silver Street, Coningsby, Lincolnshire, LN4 4SG (2) United Lincolnshire Hospitals NHS Trust 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. 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: 17/05/2024 Regulation 28 – After Inquest Document Template Updated 30/07/2021 Jayne WILKES H M Area Coroner for Greater Lincolnshire Regulation 28 – 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.
Jayne Wilkes H M Area Coroner for Greater Lincolnshire The Myle Cross Centre Macaulay Drive Lincoln LN2 4EL Your reference: Dear Ms Wilkes Lincolnshire Integrated Care Board Bridge House The Point Lions Way Sleaford NG34 8GG Tel: Email: In the matter of inquest touching the death of the late Jonathan Paul Szczepanski – Response from Lincolnshire Integrated Care Board I am responding on behalf of Lincolnshire ICB at the request of our Chief Executive, Mr John Turner, who I have briefed on the case and our response. I have now reviewed your request with contribution from our Medicines Optimisation team and respond to each of the points raised in the report as stated below. 1. There is a lack of local practitioner guidance on the practical implementation of the NICE NSAIDs – prescribing issues documentation. ICB response It is long-standing accepted practice, as per NICE guidelines, that PPIs should be considered as a co-prescription with NSAIDs for at risk patients. ICB Actions 1. The ICB will add a statement to the Lincolnshire Formulary in way of a reminder of the use of PPIs with NSAIDs. 2. The ICB will highlight the NICE guidelines in the “hot topic” article in the next Medicines Optimisation newsletter. This will also be shared in the primary care Bulletin. 3. This will be shared as a case study at the Medicine Safety Network meeting and the Prescribing Forum, including a reminder of the NICE guidelines 2. The software being used to prescribe NSAIDs did not automatically generate a specific warning flag to alert the prescriber to the considerations and risk factors in the prescription of NSAIDs (including the use of PPI). ICB response Lincolnshire ICB has two software systems in place to assist prescribing of NSAIDs, OptimiseRx and Eclipse. , Acting ICB Chair and , Chief Executive www.lincolnshire.icb.nhs.uk OptimiseRx has an automated alert at the time of prescribing NSAIDs. This comes up as a pop up to remind the clinician issuing the NSAID that they should consider adding a PPI to the prescription. Eclipse generates a weekly report regarding prescriptions of NSAIDs and identifies where co-prescribing of PPIs has not occurred. The practice can use this data to retrospectively review the patient record and add or change the appropriate medication. The ICB is working with all practices to highlight the importance of using these tools. 3. Where repeat prescriptions were issued on discharge of a patient from hospital back to community primary care, there was no warning on the discharge documentation to alert the prescriber to the considerations and risk factors in the prescription of NSAIDs (including the use of PPI). ICB response At the point of discharge from hospital a list of all medications is produced and is sent to the relevant GP practice. The ICB understands that the Trust is putting in place an electronic patient record that should make this more visible. We will work with the Trust to develop systems that promote safer prescribing which will include work with the safety lead to resend a reminder of the importance of co-prescribing a PPI with NSAID, and we plan to monitor this through our Quality forum. We are committed to working collaboratively with our relevant partners to implement changes from the lessons learnt from this case. Should you require and further information or clarification on any of the points please do not hesitate to contact me. Your faithfully Medical Director Lincolnshire ICB
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