Prevention of Future Deaths reports · 2024
Regulation 28 report to prevent future deaths, reference 2024-0353, written 26 Jun 2024. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 26 Jun 2024 |
|---|---|
| Reference | 2024-0353 |
| Deceased | Raymond Watkins |
| Coroner | Joanne Kearsley |
| Coroner area | Manchester North |
| Category | Hospital Death (Clinical Procedures and medical management) 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.
REGULATION 28: REPORT TO PREVENT FUTURE DEATHS (1) REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: 1. Rt Hon Victoria Atkins, Department of Health And Social Care, 39 Victoria Street, London, SW1 H 0EU CORONER I am Joanne Kearsley, Senior Coroner for the Coroner area of Manchester North 2 CORONER'S LEGAL POWERS I make this report under paragraph 7, Schedule 5, of the Coroner's and Justice Act 2009 and Regulations 28 and 29 of the Coroners (Investigations) Regulations 2013 3 INVESTIGATION and INQUEST On the 21 st December 2022, I commenced an investigation into the death of Raymond Horace Watkins. Raymond Watkins died on the 28th November 2022 at Royal Oldham hospital. The investigation concluded on the 26th June 2024. The medical cause of death was confirmed as 1a) Septicaemia 1b) Insulin controlled Type 2 Diabetes, Chronic Obstructive Pulmonary Disease, lschaemic Heart Disease, Pressure Ulcers 2) Cerebrovascular Accident 4 CIRCUMSTANCES OF DEATH Mr Watkins had been admitted to hospital on the 4th November 2022. During this admission he was placed on end of life palliative care and his usual medications including his insulin were stopped. He was discharged from hospital on the 10th November 2022 to his care home. The following day Mr Watkins advised the home, his GP and others that he wanted to restart his medications including his insulin. At this stage Mr Watkins had capacity and his clinical picture had improved. The GP prescribed his insulin and the authorisation required by the District Nurses for them to administer the same. The court heard that an authorisation is required before District Nurses can administer the same. Due to administrative errors both within the GP practice and the District Nurse practice this prescription was not authorised before Mr Watkins was readmitted to hospital on the 22nd November 2022. An initial forensic post mortem had considered the medical cause of death to be directly attributable to the lack of insulin however further expert evidence concluded that the prescribing of further insulin would , in this case not have been appropriate and in any event would not have made any difference. The cause of death was therefore revised. However it was acknowledged by all Interested Persons and the expert that the breakdown in communication between the GP and District Nurses was indefensible and could in a different case have been causative. As a result of their investigation into this case the Northern Care Alliance has developed and rolled out across 4 areas of Greater Manchester a "Time Critical Medicine" process for District Nurses advising them as to which medicines are considered time critical and what steps to take if authorisations are not correctly completed on receipt. This includes: ContactinQ the Prescriber and immediately raisinQ a datix incident - Returning to the prescriber within 2 hours if correct authorisation is not received - - Escalation by end of shift to a manager Escalation following morning to the Assistant Director of Nursing The implementation of this Standard Operating Procedure which came into place in March 2024, led to the number of datix incidents increasing significantly, highlighting the widespread issue. However since its implementation this has raised the awareness amongst GPs and prescribers of errors and the numbers have declined dramatically to the point where practices are making real differences to the ability for patients to access such medicines. 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. During the course of the evidence the court heard that receipt of correct authorisations in respect of medicines is an issue faced by District Nurses in many areas of the country. Currently there is no 'Time Critical Medicine" guidance for the community setting. 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe each of you respectively 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 21 August 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 namely:- Family of Mr Watkins - - Northern Care Alliance - Abbeycare Care Home - The Alexandra Group Medical Practice 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 from. 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 Date: 26/06/2024 Signe( ~~ / r V 1 1 1 I
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.
From Minister of State for Health 39 Victoria Street London SW1H 0EU 21 August 2024 Our ref: Ms Joanne Kearsley Senior Coroner HM Coroner's Court Floors 2 and 3 Newgate House Newgate Rochdale OL16 1AT By email: Dear Joanne, Thank you for the Regulation 28 report of 26 June 2024 sent to the Department of Health and Social Care about the death of Raymond Horace Watkins. I am replying as the Minister with responsibility for prescribing. Firstly, I would like to say how saddened I was to read of the circumstances of Mr Watkins’ death, and I offer my sincere condolences to their family and loved ones. The circumstances your report describes are concerning and I am grateful to you for bringing these matters to my attention. The report noted particular concerns as follows: • During the course of the evidence the court heard that receipt of correct authorisations in respect of medicines is an issue faced by District Nurses in many areas of the country. Currently there is no “Time Critical Medicine” guidance for the community setting. In preparing this response, Departmental officials have made enquiries with NHS England as the organisation with responsibility in this area. NHS England has advised that all clinicians involved in processing medication should know how to access national and local prescribing guidance. The administration of medicines in a health care setting must be done in accordance with a prescription, Patient Specific Direction, Patient Group Direction or other relevant exemption specified in the Human Medicines Regulations 2012. Professional Guidance on the Administration of Medicines in Healthcare Settings (January 2019) covers the administration of medicines, verbal orders, transcribing and covert administration. This professional guidance has been From Minister of State for Health 39 Victoria Street London SW1H 0EU co-produced by the Royal Pharmaceutical Society and the Royal College of Nursing and provides principles-based guidance to ensure the safe administration. NHS England has advised that in reviewing the report, it appears that there were failings on both sides, (i.e. the GP practice and the district nurse service), with what appears to be a breakdown in communication and other human factors at play. Therefore, any response to address the issues will require a collective multidisciplinary approach across provider and community organisations. This case does highlight the importance of strengthening prescribing partnerships in every community setting between district nurses (who are not independent prescribers) GP practices and care homes. Each ICB with non-medical prescribing (NMP) lead should review their current and potential NMP workforce for their conurbation of district nursing services as a priority, which will mitigate against medication delay and any patient harm. NHS England further advises that insulin is a recognised time critical medication that district nursing services aim to prioritise and patients receiving straight forward insulin prescriptions are often given their insulin by healthcare support workers who have been delegated this responsibility by the registered nurse overseeing the patient’s care. (Time sensitive medicines - Care Quality Commission (cqc.org.uk). District nursing services do not cap patient referrals and it is assumed that in this case the patient will have been referred to the service and prioritised. Finally, NHS England is in the process of developing a Time Critical Medicines Safety Improvement Programme in partnership with Parkinson’s UK, Epilepsy Society, and other key stakeholders. Over the three years, the programme is set to identify opportunities for improvement and make recommendations on how to prevent harm to patients. I hope this response is helpful. Thank you for bringing these concerns to my attention. Yours sincerely,
See every Prevention of Future Deaths report matching Hospital Death (Clinical Procedures and medical management) 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.