Prevention of Future Deaths reports · 2024
Regulation 28 report to prevent future deaths, reference 2024-0457, written 16 Aug 2024. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 16 Aug 2024 |
|---|---|
| Reference | 2024-0457 |
| Deceased | Anthony Nixon |
| Coroner | Janine Richards |
| Coroner area | County Durham and Darlington |
| Category | Alcohol, drug and medication related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 2 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
REGULATION 28: REPORT TO PREVENT FUTURE DEATHS REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: 1. , Community Pharmacist and Director York Road Pharmacy, Peterlee. 2. The General Pharmaceutical Council (GPhC). 1 CORONER I am Janine Richards, assistant coroner, for the coroner area of Durham and Darlington 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. INVESTIGATION and INQUEST On the 4th of September 2023 an investigation was commenced into the death of Anthony Paul Nixon. The investigation concluded at the end of the inquest on the 15th of August 2024 . I gave a conclusion that the death was drug related and that the actions of the Pharmacy contributed more than minimally in supplying additional on multiple occasions, not in accordance with the prescription for such. The medical cause of death was :- 1a) The combined toxic effect of , and . 4 CIRCUMSTANCES OF THE DEATH Anthony Paul Nixon, aged 45 years, was found deceased on the 12th June 2023 at his home address. He died as a result of an a drug overdose, having taken a combination of to a fatal toxicity. , which in combination led and , Despite a prescription for supervised consumption of on specific days, including a home office approved form of wording on the prescription in relation to such, on a number of occasions in the period leading to his death, the deceased was given his not in accordance with the prescription which was issued for him, which was designed to reduce the obvious risks of the deceased taking additional in advance for days when the pharmacy was open, which was . 1 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)The Pharmacist in this case gave evidence that he believed that he had a in advance, and not in accordance with the discretion to provide prescription for supervised provision of maintained this was a “standard practice” when the Pharmacy was open for half a day on Saturdays. He interpreted the wording on the prescription namely “please dispense instalments due on a Pharmacy closed days on a prior suitable date” to include Saturdays when the Pharmacy was open for half a day, despite the prescriptions stipulating the specific days that the including specification of the dose each Saturday. on specific days, and was to be provided, (2)This led to a situation where the deceased was in possession of multiple doses of , on a regular basis in the period leading up a controlled drug, namely to his death, which was not in accordance with the prescription, which had been carefully considered to attempt to manage the obvious risks of such. (3)The Pharmacy had been specifically chosen by the deceased’s drug treatment provider because it was able to provide supervised administration of on a 6 day per week basis and because in their assessment this was required to attempt to manage the risks inherent in the deceased having access to multiple doses. (4)The treatment provider were not alerted to the fact that the deceased was regularly receiving additional doses of prescription they had issued, and so was unable to risk manage the suitability of the prescribing arrangements. , not in accordance with the (5)I was not reassured that the Pharmacist fully appreciates the gravity of this situation, and that in evidence he continued to maintain that he could exercise a discretion in relation to the provision of , a controlled drug, and provide this not in accordance with specific prescription instructions on the days specified when the Pharmacy was open, and further that was described as a standard practice. (6)For the avoidance of doubt, the circumstances of this case have been alerted to the General Pharmaceutical Council, as the appropriate regulator, but there has been no update received as to whether an investigation has been undertaken or any action recommended. 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 11.10.24 . 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. 2 8 COPIES and PUBLICATION I have sent a copy of my report to the Chief Coroner and to the following Interested Persons; the Family of the deceased and ‘My space’ supported housing provider. I have also sent a copy to CGL (Change Grow Live) and Humankind - drug and alcohol treatment agencies, and to the Care Quality Commission (CQC) who may find it useful or of interest. 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 your response, about the release or the publication of your response by the Chief Coroner. 9 16.08.24 3
2 responses 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.
Janine Richards Assistant Coroner, for the Coroner area of Durham and Darlington By email via: 9 October 2024 Dear Janine Richards Re: In the matter of Anthony Paul Nixon (Ref 1349-2023) Thank you for sending us the Regulation 28 report regarding the death of Anthony Paul Nixon. We are very sorry to hear about this sad death and we would like to pass on our sincere condolences to Mr Nixon’s family. By way of background, the GPhC is the independent regulator for pharmacists, pharmacy technicians and pharmacies in Great Britain. Our main job is to protect, promote and maintain the health, safety and wellbeing of members of the public by upholding standards and public trust in pharmacy. This includes maintaining a register of pharmacy professionals and premises, setting regulatory standards and investigating concerns. Following on from your office’s initial email about the case, our requests for further information and the material supplied and the subsequent PFD report, we have considered how the GPhC needs to act to protect the safety of patients, uphold standards and maintain public trust in pharmacy. The GPhC Inspection and Fitness to Practise (FtP) teams have been collaborating closely on this case. As part of this, the pharmacy has recently been inspected by one of our inspectors, who looked for evidence that the pharmacy is meeting our Standards for Registered Pharmacies. The purpose of these standards is to create and maintain the right environment in pharmacies to protect and improve people’s health and wellbeing. The inspection included looking for evidence about the governance arrangements and the way the service for people taking methadone was being delivered. This was to ensure practices in the pharmacy, including supply of daily doses of methadone on days prior to the pharmacy being closed met the requirements of the prescriptions being dispensed. The Inspection report will be published in due course, showing some minor non-compliance and advice being given. Evidence collected during the visit to the pharmacy has been shared with our FtP colleagues. The GPhC FtP team investigates concerns about individual pharmacy professionals where there may be a risk to patient safety and/or where public confidence in pharmacy could be affected. The initial assessment of this case is complete, and an investigation is open. The case has been allocated to a Case pharmacyregulation.org | info@pharmacyregulation.org |020 3713 8000 Officer who will consider the findings of the GPhC inspection and whether any further evidence is required. Once the investigation is complete, we will assess the evidence in line with our Threshold Criteria to determine whether further action against the individual pharmacist is required. The details of this case have been discussed with our NHS colleagues in the Accountable Officer team and with the local CD police liaison officer to share any learnings from this case and further actions may be determined by the FtP investigation outcomes. We hope this information is helpful. If you should require any further information, please do not hesitate to contact me. Yours sincerely, Chief Executive and Registrar
York Road Pharmacy 60 York Rd, Peterlee, County Durham, SR8 2DP 11 November 2024 Dear Janine Richards, Thank you for sending the Regulation 28 report regarding the death of Anthony Paul Nixon. We are very saddened to hear about the death of Mr Nixon and I would like to express our deepest condolences to his family and friends. York Road Pharmacy is a long-established community pharmacy in Peterlee, County Durham. I am the Superintendent Pharmacist and have been here on a full-time basis for the past 5 years. Following on from my attendance at the Inquest and the receipt of the subsequent PFD report, we have considered the matters of concern and the actions to be taken to ensure this does not happen again. We have found the Durham County Council Drug and Alcohol Service Briefing Note: October 2024 helpful in this regard. This briefing describes the flexibility provided by the standard Home Office wording on FP10(MDA) prescriptions, describes changes to the Pharmacy Treatment Agreement and provides an update on how pharmacies can contact the service. We will endeavour at all times to implement and operate within the scope of this guidance going forward. As the guidance indicates, when Agreements are received by the pharmacy we will check that the Service has indicated the correct days of the week on which the supervised consumption service is normally available and inform the Service of any changes. We understand from the guidance on the Home Office approved wording that this is added to prescriptions to enable advance supplies on bank holidays, public holidays, or other irregular or emergency pharmacy closures and does not include advanced supplies for a regular closure of the pharmacy. We have discussed these requirements internally and all staff are aware of the actions required and have considered the guidance fully. I have ensured that staff have fully understood the guidance and the steps we must take. The details of the case have been discussed with the GPhC Inspector and the Local Pharmaceutical Committee Chief Officer. We are in contact the GPhC as part of their investigation and will implement any actions required as a result. Yours sincerely, York Road Pharmacy
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