Prevention of Future Deaths reports · 2024
Regulation 28 report to prevent future deaths, reference 2024-0651, written 26 Nov 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 Nov 2024 |
|---|---|
| Reference | 2024-0651 |
| Deceased | Amy Butcher |
| Coroner | Nigel Parsley |
| Coroner area | Suffolk |
| Category | Alcohol, drug and medication related deaths · Mental Health related deaths · Suicide (from 2015) |
| 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 DEATHS THIS REPORT IS BEING SENT TO: Secretary of State for Department of Health & Social Care The Chief Executive of Norfolk and Suffolk NHS Foundation Trust 1 CORONER I am Nigel PARSLEY, HM Senior Coroner for the coroner area of Suffolk 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 19th May 2023 I commenced an investigation into the death of Amy Jade BUTCHER The investigation concluded at the end of the inquest on 1st November 2024. The conclusion of the inquest was that the death was the result of:- Suicide as the result of a deterioration in her mental health, exacerbated by an ineffective PRN medication prescription which failed to resolve her heightened anxiety crisis when needed. The medical cause of death was confirmed as: 1a Fatal Pressure on Neck 4 CIRCUMSTANCES OF THE DEATH Amy Butcher was declared deceased at 07:26 hours on the 14th May 2023 at in Suffolk. Amy had been found inside the premises, . Amy was being treated by Mental Health services and had four days earlier (10th May 2024) been admitted to A&E in a heightened anxiety crisis and wanting to die. At this time Amy was given Lorazepam (a ‘pro re nata’ [PRN] ‘take as needed’ medication). This medication was very effective for her, and once her anxiety crisis had passed, she was allowed home. Following her discharge Amy had consultations with her mental health crisis team and her GP, and made repeated requests for a prescription of Lorazepam, to take as a PRN medicine, if she suffered a further heightened anxiety crisis. Taking a PRN medication was one of the steps identified in Amy’s agreed crisis plan. Regulation 28 – After Inquest Document Template Updated 30/07/2021 Amy’s request for Lorazepam was declined, and alternative PRN medications where subsequently prescribed. On the evening of the 13th May 2024 Amy was particularly distressed, and it took her partner hours to calm her down, until Amy finally fell asleep. At some point Amy had taken her prescribed PRN medication (as evidenced in subsequent toxicology analysis), but in the early hours of the 14th May 2023, Amy awoke and suspended herself with a ligature around her neck. Amy’s prescribed PRN medication had therefore not alleviated her heightened anxiety crisis. Had Amy had access to Lorazepam as a PRN medication on the evening of the 13th May 2023 (knowing the positive outcome this had for her on the 10th May 2023), it is more likely than not, that her death would not have occurred. Notes written by Amy, and disclosed to the Mental Health on the 8th May 2023, addressed to her loved ones, indicate that she premediated thoughts about taking her life, and therefore intended her death. 5 CORONER’S CONCERNS During the course of the investigation my inquiries 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: (brief summary of matters of concern) 1. Evidence heard at inquest identified a muddled and unclear system for the prescription of medication to someone in Amy’s situation. The Emergency Department Consultant who saw Amy in crisis on the 10th May 2024 stated that for patients like Amy she had previously prescribed Lorazepam upon discharge home, but could only do this if the Mental Health Team in the ED requested her to do so, which they did not do on this occasion. The following day, Amy herself tried to obtain a prescription of Lorazepam by dialling NHS 111 Option 2 (Mental Health line). She spoke to a mental health practitioner who told her that NHS 111 Option 2 did not have the ability to prescribe medication, and she would need to call NHS 111 Option 1 and speak to an Out of Hours GP instead. Amy contacted NHS 111 Option 1 and spoke to an Out of Hours GP, who worked for a private company which had implemented a ban on the prescription of Lorazepam due to its highly addictive properties. As such, even if the GP had considered Lorazepam to be required in Amy’s case, he could not have prescribed it. The GP prescribed different PRN medications, which were subsequently found in Amy’s system after her death. Amy’s own GP gave evidence stating that the system for prescribing mental health medication was confusing. He stated that mental health medications prescribed to a patient by a GP (such as antidepressants) before a Mental Health Team became involved, remained the responsibility of the GP. Regulation 28 – After Inquest Document Template Updated 30/07/2021 However, once a Mental Health Team became involved, any changes to the medication regime could only be made by the Mental Health Team. In addition, some medication would be prescribed by the Mental Health Team directly, whilst other would be prescribed separately by the GP. The GP described the situation as one of there simply being ‘too many chiefs’. The net effect of the current system in place is that an individual in Amy’s situation finds themselves needing to make multiple telephone calls or contacts with NHS 111 Option 1, NHS 111 Option 2, their Out of Hours GP Service, their own GP and their Mental Health Team, in order to try and obtain either a new prescription or change their current prescription if their mental health suddenly deteriorates. There is evidently no single point of contact, or single decision maker regarding prescriptions in these cases. The evidence suggests that the situation is exacerbated even further if the individual’s mental health deterioration occurs Out of Hours. 2. Evidence was heard that a decision had been made by the Mental Health Multi-Disciplinary Team that Lorazepam was not to be prescribed to Amy in any event. The court heard that Lorazepam was highly addictive and the subject of frequent misuse by individuals to whom it was prescribed. There were two reasons given for the MDT decision. Firstly, Amy had volunteered to the Mental Health Team, that she had previously purchased online a ‘micro dose of hallucinogenic mushrooms’ to try and alleviate her systems. The court heard that like ‘homeopathic medication’ only a tiny amount of the active hallucinogen found in mushrooms would have been present, but that it was still illegal to possess this in the UK. Amy had told the team that she had only used this once. The MDT decision was that because this was an illegal drug, because the MDT were unaware that micro dosing of hallucinogenic mushrooms was being used by mental health patients, and because they did not know how it would react with the Lorazepam, no Lorazepam was to be prescribed to Amy. Secondly, Amy had previously disposed of medications prescribed to her which made her feel worse (a known side effect of some medications in the first few days of taking them). When advised to restart them, repeat prescriptions had to be made. In addition, just prior to her death Amy volunteered that she had been taking a sleeping tablet (Zopiclone) in the mornings, as well as taking them when she was supposed to at night. Amy had said that her current PRN medication had no effect, but the Zopiclone did help. As a result, it was recorded by the MDT that Amy was ‘non-concordant’ with her medication regime, therefore making her a higher risk of prescription misuse. However, in her evidence, the Emergency Department Consultant said she was fully aware of the fact that micro dosing of hallucinogenic mushrooms was being used by mental health patients, and that due to the tiny amount Regulation 28 – After Inquest Document Template Updated 30/07/2021 of active hallucinogen it was generally not a barrier to the prescription of any other medication. In addition, the Emergency Department Consultant stated that if an individual had ingested a toxic quantity of hallucinogenic mushrooms, there was no contra-indication for the prescription of Lorazepam as it was often prescribed to reduce the hallucinogenic effects. In the evidence heard from members of the MDT, it was clear that the illegal use of a ‘micro dose of hallucinogenic mushrooms’ coupled with Amy’s non-concordance, led to the decision not to prescribe her Lorazepam. As such, a lack of knowledge in relation to the common usage of micro dose hallucinogenic mushrooms as a self-treatment by mental health patients, a lack of knowledge in relation to there being no contra- indications for the prescription of Lorazepam if micro dose hallucinogenic mushrooms were being used, and defining Amy as ‘non-concordant’ due to her use of Zopiclone when her PRN medication proved ineffective, prevented a realistic opportunity for the MDT to consider if Lorazepam should have been prescribed to Amy. 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 January 21, 2025. I, the Senior 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: Amy’s next of kin I am 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. She may send a copy of this report to any person who she believes may find it useful or of interest. You may make representations to me, the Senior Coroner, at the time of your response, about the release or the publication of your response by the Chief Coroner. 9 Dated: 26/11/2024 Nigel PARSLEY HM Senior Coroner for Suffolk Regulation 28 – After Inquest Document Template Updated 30/07/2021
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.
Parliamentary Under-Secretary of State for Patient Safety Women’s Health and Mental Health 39 Victoria Street London SW1H 0EU Our ref: Nigel Parsley HM Senior Coroner for the coroner area of Suffolk The Coroner’s Court and Offices, Beacon House, Whitehouse Road, Ipswich IP1 5PB By email: 21 January 2025 Dear Mr Parsley, Thank you for the Regulation 28 report of 26 November 2024 sent to the Secretary of State for Health and Social Care about the death of Amy Jade Butcher. I am replying as the Minister with responsibility for Mental Health. Firstly, I would like to say how saddened I was to read of the circumstances of Amy Butcher’s death and I offer my sincere condolences to their family and loved ones. Every suicide is a tragedy that has a devastating and enduring impact on families, friends and communities. The circumstances your report describes are concerning and I am grateful to you for bringing these matters to my attention. Your report detailed your concerns over the local protocols in place for the prescription of medicines to people in mental health crisis, and over the mental health team’s decision not to make a further prescription of lorazepam to Amy, despite this drug having been effective for her a few days before her death. In preparing this response, my officials have made enquiries with NHS England and the National Institute for Health and Care Excellence (NICE) to ensure we adequately address your concerns. NICE have reviewed their guideline CG113 on the management of generalised anxiety disorder (GAD) and panic disorder in adults, against your report. They have concluded that the guideline addresses the concerns raised by this very sad case as it covers which medicines should, and should not, be prescribed for the treatment of GAF in different circumstances. NHS England have considered how this case was managed. As you suggest in your report, there remains a concern about the clarity for prescribing for mental health across local systems. As an action, the NHS England National Specialty Advisor for Mental Health Pharmacy will now write to mental health Chief Pharmacist colleagues across England and request that that they ask their local systems and prescribing committees to review their local mental health prescribing policies to ensure that all relevant stakeholders have clarity about prescribing responsibilities across primary care/secondary care and emergency departments, including out of hours arrangements and crisis team prescribing protocols . Further, in August 2024 NHS England announced the introduction of access to local ‘select mental health option’ (see ageappropriate crisis services via NHS 111 https://www.england.nhs.uk/2024/08/nhs-111-offering-crisis-mental-health-support-for- thefirst-time/). It is not currently feasible to include prescription of medication under this service. NHS England has therefore introduced a fail-safe system whereby patients with medication queries or requests are advised to select option 1 (prescribing) when calling NHS 111. This acknowledges that most open crisis services are unable to prescribe medication. This should make the process easier and much clearer for patients. NHS England recognises that the triage and assessment elements of this new service is in parts of the country commonly outsourced to VCSE organisations where prescribing medication is not feasible at the moment. It is therefore not in a position to make a commitment to include prescribing in NHS 111 Option 2. We need to allow these services time to grow and align nationally. In the longer term NHS England hope to explore how these services can be aligned to include prescribing of medication if appropriate and safe to do so. I hope this response is helpful. Thank you for bringing these concerns to my attention. Yours sincerely, PARLIAMENTARY UNDER-SECRETARY OF STATE FOR PATIENT SAFETY, WOMEN’S HEALTH AND MENTAL HEALTH
Senior Coroner, Nigel Parsley Suffolk Coroner’s Court Beacon House Whitehouse Road Ipswich IP1 5PB Email: By email only Dear Senior Coroner Parsley NSFT Trust Management Norfolk & Suffolk NHS Foundation Trust Floor 7 County Hall Martineau Lane Norwich NR1 2DH Tel: 01603 421421 Date: 17th January 2025 Regulations 28 and 29 (coroners investigations regulations 2013) notification made in response to the death of Amy Butcher I write in response to the Regulation 28 report made on 26th November 2024 in respect of concerns raised at the inquest touching the sad death of Amy Butcher which concluded on 1st November 2024. I have reviewed the report in its entirety and provide responses below each summarised concern for ease of reference. 1. There is evidently no single point of contact, or single decision maker regarding prescriptions in cases like Amy’s, which is exacerbated further out of hours; I can confirm that the NHS 111 Mental Health Option telephone support line operated by NSFT is not commissioned to provide medication prescriptions. I recognise that Amy interacted with multiple prescribing pathways within the NHS system and whilst NSFT is not the responsible commissioner for NHS 111 Option 1, GP surgeries or out of hours GP services we have raised the issue with our Integrated Commissioning Boards with a view to identifying any possible improvements that can be made as a result of the concern raised. Prescribing pathways within NSFT are set out in our Management of Medicines Policy and includes inpatient, outpatient and Crisis Resolution and Home Treatment teams ‘CRHT’. Crisis Resolution & Home Treatment teams have three prescribing options available: (i) FP10s which should be avoided where possible as it relies upon a service user to source the required medication from a pharmacy directly; (ii) Electronic Patient Medication Administration (EPMA) system. Medications are dispensed from the Trust’s central pharmacy at Hellesdon Hospital, Norwich, to satellite bases around the county, this means there is variation in the delivery timeframe. Option 3 is designed to help mitigate this. (iii) Each CRHT base has a limited stock of various of pre-packed medications which can be provided to service users. The amount included in the pre-packed medications is a 3-day supply. I note in the NSFT staff evidence they had requested Amy to ask the GP for a further prescription and increase of her antidepressant medication which was prescribed by the GP prior to referral to CRHT. The clinical rationale for this was to reduce the risk of medication errors, however, while the intention of this is to provide safe care, in circumstances where a patient may be distressed, and there is a risk of Trust HQ: County Hall, Martineau Lane, Norwich, NR1 2DH Tel: 01603 421421 Web: www.nsft.nhs.uk 1 non-adherence, best practice would have been for the CRHT staff to have contacted the GP directly to make this request. Further, I noted the GP’s evidence in respect of the complexity of prescribing mental health medications. To simplify the position, we have added the following information to our standard letters which are sent to GPs when service users are taken onto CRHT caseloads: Your patient has been accepted for treatment under the Crisis Resolution & Home Treatment team. Please continue to prescribe all physical health medications and advise CRHT in the event that you make changes. We will advise you if we need you to review physical health medications as a result of any prescriptions we commence. Please continue to prescribe all mental health medications that were prescribed at the point of referral unless we advise you otherwise. This information will provide clarity for both GPs and CRHT teams and means that GPs can confidently continue to prescribe all medications they had been prescribing prior to CRHT involvement and CRHT can make prescribing decisions with the knowledge of which medications GPs are already prescribing. Staff have been reminded of the need to liaise directly with GPs with any requests to adjust medications already prescribed by GPs in the circumstances described above. By way of assurance, the clinical audit team will undertake a joint audit with primary care colleagues 3 months post implementation of the above wording being introduced, the results of which will be reported to our Trust wide Safety Group for consideration. 2. A lack of knowledge in relation to the common usage of microdose hallucinogenic mushrooms as a self-treatment by mental health patients, a lack of knowledge in relation to there being no contraindications for the prescription of Lorazepam if micro dose hallucinogenic mushrooms were being used, and defining Amy as ‘non-concordant’ due to her use of Zopiclone when her PRN medication proved ineffective, prevented a realistic opportunity for the MDT to consider if Lorazepam should have been prescribed to Amy I note your record of the evidence given by the A&E Consultant was that they could only prescribe Lorazepam on discharge if the mental health team requested this. Upon enquiring further, I understand that the agreed process with our acute hospital colleagues is that where a patient has been deemed medically fit for discharge, subject to mental health assessment, the A&E Consultant would have no further involvement unless the mental health liaison staff specifically requested prescription of medication and it is in that context that the A&E Consultant would only prescribe on discharge if the mental health team requested it. It therefore remains open to an A&E Consultant to prescribe without reference to the mental health team if it is their clinical view that the same is necessary. In this case, the mental health liaison team had access to the clinical records of the CRHT and as a result made the clinical decision not to request any further prescription of Lorazepam. However, we know we can always improve our communication and services with our acute hospital colleagues and as a result we have recently implemented a new Standard Operating Procedure for our mental health liaison teams within the acute hospitals in Norfolk & Waveney. This documents clearly outlines the aims, objectives and expectations of our mental health liaison services within acute hospital settings. A copy of this document is enclosed for your information. I note that the A&E Consultant gave evidence regarding prescription of Lorazepam where micro-dosing of hallucinogenic mushrooms was known was generally not a barrier, there was no contra-indication, and it 2 was often prescribed to reduce the hallucinogenic effects. However, the evidence of the A&E Consultant must be considered in the context of prescribing in a controlled ward environment as opposed to CRHT staff potentially prescribing in the community. Our Chief Pharmacist office has advised that the British National Formulary does not, as a standard, list illegal substances as contra-indications. Our Chief Pharmacist’s office has undertaken a search of available studies/evidence to guide clinicians in to this area and has benzodiazepines/lorazepam. We have also liaised with our drug and alcohol service system partners in Norfolk and Suffolk and our system colleagues did not have any specific guidance in respect of the same. limited, with no specific studies related to be extremely found it Our clinicians will adhere to their professional codes, national and regulatory guidance in conjunction with the Trust’s Management of Medication Policy. However, we remain committed to providing our services based upon best available medical evidence and we will continue to monitor the developments in this area for implementation in accordance with NICE or other regulatory guidance in the future. Yours sincerely, Chief Executive Officer 3
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