Prevention of Future Deaths reports · 2024
Regulation 28 report to prevent future deaths, reference 2024-0484, written 9 Sep 2024. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 9 Sep 2024 |
|---|---|
| Reference | 2024-0484 |
| Deceased | Amanda Richardson |
| Coroner | Kevin McLoughlin |
| Coroner area | West Yorkshire (East) |
| Category | Alcohol, drug and medication related deaths · State Custody related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
Text recovered by OCR from a scanned PDF. OCR is imperfect: check anything you rely on against the source PDF. Reproduced verbatim, including the scan's own layout.
OFFICE OF THE
SENIOR CORONER
for the County of West Yorkshire
{Eastern District)
His Majesty’s Coroner's Office
The Coroner's Courts
Burgage Square
Wakefield WF1 2TS
REGULATION 28 REPORT TO PREVENT FUTURE DEATHS
THIS REPORT IS BEING SENT TO:
1. Waterloo Manor Hospital
2. In Mind Healthcare Group Limited
CORONER
| am Kevin McLoughlin, Senior Coroner, for the Coroner area of West Yorkshire (East)
CORONER’S LEGAL POWERS
| make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and
regulations 28 and 29 of the Coroner's (Investigations) Regulations 2013.
INVESTIGATION and INQUEST
On 31 May 2023 | commenced an investigation into the death of Amanda Richardson, aged 40.
The investigation concluded at the end of the Inquest on 30 August 2024. The conclusion of the
7 was a narrative conclusion, in which the medical cause of death was:
4a and DT oxicity.
~ [CIRCUMSTANCES OF THE DEATH
Amanda Richardson, aged 40, had been transferred from prison to a low secure mental health
hospital called Waterloo Manor Independent Hospital in Leeds, under the provisions of a
Hospital Order made under the Mental Health Act 1983.
She was prescribed the drug amongst other medication.
On Saturday 29 April 2023, Ms Richardson was pronounced dead by a paramedic after her
lifeless body was found on the floor of her bedroom.
Toxicology Analyses subsequently revealed lat a very high level well within the
range encountered in fatalities, along wit!
It transpired she had in error been prescribed ae double the stipulated maximum
dose.
iCORONER’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. The evidence taken at the inquest revealed that Ms Richardson had been prescribed
mamma for a period of about six months at double the stipulated maximum dose. The
pathologist expressed the view that the “very high” level of oor in her blood_on
toxicology analysis could possibly account for her death on its own. had also taken
Her death was attributed to the toxicity of both th nd [in combination.
2. It was admitted that the prescription of the rate of fng/day was double the
mg/day stipulated maximum (without additional monitoring being undertaken) and was
made in error. This situation went unnoticed for some six months, until her death. There was no
effective system of review in the hospital in this period. The pharmacist appears to have
dispensed the drug without querying the high dose. The nurses who administered the drugs did
not question it. The MDT meetings which took place did not check the dose, or reflect upon its
potential interaction with the several other medications prescribed. Overall, there was no
effective resilience in the hospital's systems to safeguard against drugs bring prescribed or
administered in error.
3. On 19.4.23, Ms Richardson was permitted unescorted leave in the community under S.17
MHA 1983. She did not return. She did, however, voluntarily reappear at the hospital the
following day, albeit under the influence of illicit drugs and alcohol. Evidence was given that
nurses reported having searched Ms Richardson on her return, but no adequate written record
was made to confirm the nature or duration of the search, nor by whom it was conducted, in
breach of hospital policies.
4. Ms Richardson died some 9 days later. Despite the seriousness of the 19.4.23 incident, no
searches were carried out in her room or the hospital grounds in the period following her return.
The toxicology and pathological evidence indicated that she had taken heroin shortly before her
death. Her room was not searched even after her death, as assumptions were wrongly made
that her death was due to a cardiac event.
5. Some time after hear death, Ms Richardson's clothing and belongings were returned to an
aunt. She searched through them and found various plastic “wraps” which were taken to the
police and subsequently tested and confirmed as containing Mn The
inference is that these were present in her bedroom at the time of her death.
6. The inquest was unable to establish how or when Ms Richardson obtained illicit illegal drugs.
Concerns were expressed as to the adequacy of the security arrangements in this low secure
mental health hospital as at April 2023.
7. In fairness to the hospital, it should be acknowledged that an Internal Serious incident Review
has taken place. Evidence was taken from the Group Deputy Chief Executive in relation to the
overhaul of security systems, pharmacy review procedures, staff training and record keeping
which has taken place since Ms Richardson's death.
ACTION SHOULD BE TAKEN
In my opinion action should be taken to prevent future deaths and | believe your organisation
has the power to take such action.
YOUR RESPONSE
You are under a duty to respond to this report within 56 days of the date of this report, namely by
1 November 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.
COPIES and PUBLICATION
| have sent a copy of my report to the Chief Coroner and to the following Interested Persons who:
may find it useful or of interest. :
~ “1
ae
The CQC
The GMC
West Yorkshire Police
lam 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.
Signed:
KEVIN McLOUGHLI
Senior Coroner
West Yorkshire (E)
Date: 9 September 2024 _|
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.
Our Ref: Your Ref: 6 November 2024 Mr Kevin McLoughlin Senior Coroner West Yorkshire (East) Coroner's Office 71 Northgate Wakefield WF1 3BS RESPONSE TO REGULATION 28 REPORT Dear Sir Inquest Touching the Death of Amanda Richardson We write in response to the Regulation 28 Report dated 9 September 2024 following the inquest touching the death of Amanda Richardson. Following Amanda's sad death, Inmind Healthcare completed a Serious Incident Report which shared with the CQC and Commissioners prior to the Inquest. The Serious Incident Report included an action plan of recommendations arising from the findings of the report. The details of the steps and actions implemented and embedded by Inmind following this incident were detailed at length within a witness statement of and in oral evidence of and Hospital Director at the inquest. The evidence included both changes to practice arising directly from this case and further improvements to service due to further organisational change. We do not intend to repeat in detail their evidence and consider that given the assurances before the Court at the inquest demonstrate that Inmind had learned lessons from this case and implemented change to prevent future deaths. We note that the Coroner has not specified any particular concerns arising from that evidence or identified a circumstance giving rise to risk of future deaths. On clarifying this with Coroner he states that he DAC Beachcroft - an international law firm DAC Beachcroft LLP is a limited liability partnership registered in England and Wales (registration number OC317852) which is authorised and regulated by the Solicitors Regulation Authority (authorisation number 440774). Our registered office is 25 Walbrook, London EC4N 8AF. Please read our DAC Beachcroft privacy policy at www.dacbeachcroft.com. considers his duty to make a prevention of future death report was triggered because of the seriousness of the case and that he felt a public record should be made of these concerns but did list concerns (as required with reference to paragraph 22 of the Chief Coroner's Guidance]. Further the Coroner stated that he has made a report notwithstanding the "assurances" given by Inmind Healthcare Inmind Healthcare remain committed to learning and improving service but given the assurances given to the Coroner at the Inquest, Inmind Healthcare consider that actions have been taken to fully address the issues identified by the Serious Incident Report and to prevent future deaths in similar circumstances. Yours faithfully Inmind Healthcare
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