Source · Prevention of Future Deaths

Steven Allen

Ref: 2021-0190 Date: 2 Jun 2021 Coroner: Alison Mutch Area: Greater Manchester South Responses identified: 1 / 1 View PDF

Strong pain medication was prescribed to a patient with a history of drug addiction and self-harm, often through remote consultations, with insufficient challenge or oversight regarding their chaotic lifestyle.

Date 2 Jun 2021
56-day deadline 28 Jul 2021 est.
Responses identified 1 of 1
Alcohol, drug and medication related deaths Community health care and emergency services related deaths

Coroner's concerns

AI summary
Strong pain medication was prescribed to a patient with a history of drug addiction and self-harm, often through remote consultations, with insufficient challenge or oversight regarding their chaotic lifestyle.
View full coroner's concerns
The inquest heard evidence that he had a chaotic lifestyle and a history of drug addiction. He was in significant pain and was prescribed medication to manage his pain including oxycodone. He was prescribed this and additional medications although there was a history of addiction, self-harm and poor use of prescribed and illicit substances. Prescribing of these medications was done through telephone consultations due to Covid 19 and on occasion additional replacement prescriptions were given with little challenge.

Responses

1 respondent
Stockport Clinical Commissioning Group NHS / Health Body
7 Jul 2021 PDF
Action Planned

Stockport CCG's Medicines Management Team is in discussion with Primary Care Network Leads to explore how the Stockport Integrated Pharmacy Service can support practices in medication reviews for vulnerable patients. Stockport GPs will be reminded of available resources for opioid prescribing support. (AI summary)

View full response
Dear Ms Mutch Steven Allen I refer to the Regulation 28 Prevention of Future Deaths Report relating to the above named and thank you contacting NHS Stockport Clinical Commissioning Group (CCG) in this matter. am sorry to learn of the death of Allen and would ask that you pass on my sincere condolences to his family at this difficult time_ You explain that Mr Allen had a chaotic lifestyle and history of drug addiction and raise concern that despite this history , medication including Oxycodone, were prescribed via telephone consultation due to Covid 19 and on occasion replacement prescriptions were given with little challenge: The Practice take on board the comments included within the Regulation 28 Report and have undertaken review of this case and looked at their processes for the management of prescribing for patients in this vulnerable cohort; The practice are satisfied that this was an isolated case and that all clinicians do adhere to guidance in relation to informed prescribing and support of this patient group. As the commissioners of healthcare services for the Stockport population, Stockport CCG is keen to ensure that we learn from patient experience and consistently improve Mr

the services we provide_ In response to this case I can confirm that the following steps are in place to address the issue highlighted in this case: _ We acknowledge that drugs causing addiction is system wide healthcare challenge in Stockport and nationally_ can confirm that the review of high opioid prescribing and other drugs causing addiction has been highlighted in the national DES contract: The Medicines Management Team is currently in discussion with the Primary Care Network (PCN) Leads to explore the Stockport Integrated Pharmacy Service (SIPS) can support GP Practices in optimising medication reviews for this patient cohort; There are currently also resources available within Primary Care to support practices with high opioid prescribing; these are as follows:- Greater Manchester Medicines Management Group (GMMMG) Opioid Prescribing for Chronic Pain; Resource Pack Inappropriate Polypharmacy Review and Treatment Optimisation: Resource Pack Stockport GPs will be reminded of the availability of these resources and how to seek support in the next pharmacy newsletter. I do not under estimate the impact of addiction on any individual and/or their family and whilst I am mindful that I cannot undo what happened in this case, I hope Mr Allen's family will be reassured that steps are being taken to support our GPs in the prescribing of medications linked to addiction.

Report sections

Investigation and inquest
On 26th October 2020 I commenced an investigation into the death of Steven Allen. The investigation concluded on the 24th May 2021 and the conclusion was one of drug related death. The medical cause of death was combined drug toxicity.
Circumstances of the death
On 25th October 2020 Steven Terence Allen was found unresponsive at his home address, 26 Dunton Towers. Police investigation found no suspicious circumstances and no evidence of third party involvement in his death. Post mortem examination included toxicology. Toxicology found that he had a fatal level of prescribed medication in his system.

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Report details

Reference
2021-0190
Date of report
2 June 2021
Coroner
Alison Mutch
Coroner area
Greater Manchester South

Responses identified

Responses identified 1 of 1
All listed responses identified

Organisations named in PFD reports are normally expected to respond within 56 days. Deadline: 28 Jul 2021 (estimated).

Sent to

Stockport Clinical Commissioning Group

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