Source · Prevention of Future Deaths

Amanda Hesketh

Ref: 2022-0183 Date: 17 Jun 2022 Coroner: Chris Morris Area: Manchester South Responses identified: 2 / 2 View PDF

The practice failed to systematically review patients on multiple repeat analgesics or create individual plans, relying on repeat prescriptions without specialist input. There were also concerns about limited access to specialist pain clinics and underutilization of practice pharmacists for complex pain management.

Date 17 Jun 2022

56-day deadline 12 Aug 2022

Responses identified 2 of 2

Alcohol, drug and medication related deaths

Coroner's concerns

AI summary

View full coroner's concerns

1. Notwithstanding the actions the practice has taken in response to Mrs Hesketh’s death, it is a matter of concern the partnership has yet to undertake or commission a systematic review of all patients receiving repeat prescriptions of multiple analgesics and formulate individual plans for each such patient; To the Secretary of State for Health and Social Care
2. The court heard evidence from a General Practitioner as to difficulties patients encounter in accessing services from specialist pain clinics with lengthy waiting lists often being experienced. It is a matter of concern that patients being prescribed multiple analgesics continue to receive such medicines on repeat prescription with often with little or no specialist input;
3. It is a matter of concern that GP practices who have a significant number of patients with complex analgesia regimes do not universally engage practice pharmacists to complement the knowledge of doctors and enhance the advice provided to patients.

Responses

2 respondents

Department of Health and Social Care Central Government

10 Jan 2023 PDF

Action Planned

The Department of Health and Social Care highlights existing support for pharmacists in General Practice via Primary Care Networks (PCNs) and the Additional Roles Reimbursement Scheme (ARRS). It also mentions the National Overprescribing Review and its implementation program, along with the role of Integrated Care Boards (ICBs) in commissioning specialist pain clinics. (AI summary)

View full response

Dear Mr Morris,

Thank you for your letter of 17 June 2022 about the death of Mrs Amanda Hesketh. I am replying as Minister with responsibility for Primary Care and Public Health at the Department of Health and Social Care.

Firstly, I would like to say how saddened I was to read of the circumstances of Mrs Hesketh’s death and I offer my sincere condolences to her family and loved ones. The circumstances your report describes are very concerning and I am grateful to you for bringing these matters to my attention.

In preparing this response, Departmental officials have made enquiries with NHS England and the Care Quality Commission (CQC).

In relation to your concern about General Practices engaging with practice pharmacists, you may wish to know that this Government has provided a high level of support and expectation in relation to pharmacists working in General Practice. Across England, General Practices are working together in Primary Care Networks (PCNs). One aspect of PCN work is supporting patients with structured medication reviews (SMRs), which are one of the PCN service requirements that commenced during 2020/21. Clinical pharmacists are best placed to carry out these reviews, and the Additional Roles Reimbursement Scheme (ARRS) provide PCNs with full reimbursement for clinical pharmacists amongst a variety of other roles.

In addition, from October 2020 all PCNs are required to identify patients who would benefit from a SMR, specifically those in care homes, using potentially addictive pain management medication, on medicines commonly associated with medication errors, with severe frailty, or with complex and problematic polypharmacy, specifically those on 10 or more medications. In March 2022, NHS England updated the SMR and medicines optimisation service in the Primary Care Network Contract Directed Enhanced Service (DES), to expand the list of patients eligible for a SMR to include those on potentially

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Donneybrook Medical Centre

PDF

Action Taken

Donneybrook Medical Centre has categorised and prioritised patients receiving repeat prescriptions of multiple analgesics with assistance from the Medicines Optimisation Team. A plan has been put in place to introduce a limitation on how many months prescriptions can be given before a patient's next review and safety netting has been put in place to ensure the various risk groups will always be reviewed going forward. (AI summary)

View full response

Dear Sirs Re: Death of Amanda Carole Hesketh Thank you for your Regulation 28: Report to Prevent Future Deaths dated 22"' October2021 following the inquest into the very sad death of Amanda Carole Hesketh. You concluded her cause of death was as a consequence of complications of her pain relief medication. You also highlighted your concerns that a death of this type could occur again without further action from Donneybrook Medical Centre. Donneybrook Medical Centre and I take the health and safety of our residents very seriously and I very much share your desire to prevent any such recurrence. I am grateful to you for bringing your findings to my attention and I set out below the steps that have taken place, and will be taking place, on the issues you raise.
1. We have utilised the help from of the Medicines Optimisation Team at the GMICB (previously CCG) to assist, categorise and priorotise patients receiving repeat prescriptions of multiple analgesics.
2. A search was undertaken looking at patients on multiple analgesia, to identify who had already been reviewed and who had not.
3. From the searches these patients were categorised into categories or risk and urgency: Red- Urgent, this would include no reviews on multiple analgesia including schedule 2 controlled drugs (Morphine, Fentanyl or Oxycodone). Amber- This would include no reviews on multiple analgesia including pentinoids, Gabapentin or Pregabalin. Green- This would include no review on multiple analgesia to include paracetamol, codeine and Nsaids.
4. In additional, all patients identified in the search who have already had a review within the last 12 months will be checked, quality of the review and any instructions or call backs noted. If necessary they will be added into the Red/ Amber/Green urgency categories for a

further review. The date for their next review will be added to the diary in line with recommendations.
5. Once the searches had been completed and patient groups identified a clinical meeting was held with a presentation of patients on the red priority list and a plan has been put in place to review these patients.
6. The red priority patients are in the process of being reviewed, the target for the red priority list is for it to be completed by the end of August 2022.
7. A plan has been put in place to introduce a limitation on how many months prescriptions can be given before a patient's next review; this is 3 months in the red priority, 6 months in the amber priority and 12 months in the green. Once a review is due the prescription clerk will highlight this then an appointment will be automatically made with the GP for further review.
8. Safety netting has been put in place to ensure the various risk groups will always be reviewed going forward - collating each patient's last review date and their next review date. Searches will be run every month to identify any new patients who will need adding to this group
9. The practice will recruit a pharmacist who will support this work and while the recruitment is ongoing locum agency staff will be employed.
10. Patients on the amber list are currently being reviewed with the green list will being reviewed by in-house pharmacist provision. I hope that we have provided you with the necessary assurances, with these medicines management changes, in relation to your concerns. Please contact me if you require any further information or if I can assist further in anyway. Kind Regards Operations Manager

Report sections

Investigation and inquest

On 27th August 2021, Alison Mutch OBE, Senior Coroner, opened an inquest into the death of Amanda Hesketh who died on 28th January 2021 at Tameside General Hospital, Ashton-under-Lyne, at the age of 53 years. The investigation concluded with an inquest which I heard on 6th and 7th June 2022, and which concluded with a Narrative Conclusion to the effect that Mrs Hesketh died as a consequence of complications of her pain relief medication. There was no evidence to suggest Mrs Hesketh misused her medication or took it otherwise than in accordance with prescribing directions in the period leading to her death.

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Report details

Reference: 2022-0183
Date of report: 17 June 2022
Coroner: Chris Morris
Coroner area: Manchester South

Responses identified

Responses identified 2 of 2

All listed responses identified

Organisations named in PFD reports are normally expected to respond within 56 days. Deadline: 12 Aug 2022.

Sent to

Department of Health and Social Care

Donneybrook Medical Centre

Source links

Judiciary.uk page → Report PDF →

Data: judiciary.uk under OGL.