Source · Prevention of Future Deaths

Irene Whittingham

Ref: 2020-0047 Date: 28 Feb 2020 Coroner: Rachel Syed Area: Manchester West 1 response identified · 3 indexed addressees View PDF

AI-generated concerns summaryThe coroner noted conflicting guidance for clinicians on monitoring Vitamin D and Calcium blood levels, with no advice issued to the GP for community monitoring. There were also concerns about WellSky and EMIS software allowing prescribing of doses exceeding national guidelines due to confusing dropdown menus.

Date 28 Feb 2020

56-day deadline 24 Apr 2020 est. estimated from the report date

Responses identified 1 of 3

Alcohol, drug and medication related deaths Hospital Death (Clinical Procedures and medical management) related deaths

Coroner's concerns

AI summary

The coroner noted conflicting guidance for clinicians on monitoring Vitamin D and Calcium blood levels, with no advice issued to the GP for community monitoring. There were also concerns about WellSky and EMIS software allowing prescribing of doses exceeding national guidelines due to confusing dropdown menus.

View full coroner's concerns

During the Inquest; evidence was heard that: 1_ Conflicting guidance is provided to treating clinicians as to when Vitamin D and Calcium blood level monitoring should be undertaken especially in patients who are given higher (loading) doses of Vitamin D, which exceeds the recommended national guidelines. The Consultant in Acute Adult Medicine gave evidence that he expected blood level monitoring to have taken place within 4 weeks of the loaded Vitamin D commencing; whereas the Endocrinologist, gave evidence that he expected blood level monitoring to take place around the 3 month period to ensure the course of medication had been completed: In any event, no advice or instructions were issued to the deceased GP, regarding any requirement to monitor the deceased blood levels whilst she was in the community and taking high levels of Vitamin D which exceeded national guidelines:
2. Irequest that The Chief Executive of The Royal Bolton Hospital reviews: The guidance and practices adopted by staff; in regard to when blood monitoring of the above types of patients should take place to ensure a consistent and safe approach is adopted: the being

3. The WellSky and EMIS Software, had a confusing user drop down menu option, which allowed the user to click on a twice daily dose despite the oaded dosage, exceeding national guidelines:
4. Irequest that The Chief Executives of WellSky and EMIS Software company reviews:
5. The dropdown user options to ensure better system safety nets are put in place to prevent catastrophic prescribing errors occurring in the future ACTION SHOULD BE TAKEN In my opinion urgent action should be taken to prevent future deaths and I believe that you have the power to take such action: YOUR RESPONSE You are under a duty to respond to this report within 56 of date of this report; namely by 24TH April 2020. I, the Coroner, may extend 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 Ihave sent a copy of my report to the Chief Coroner ad to the following Interested Persons: - Son of deceased Iam also under a to send the Chief Coroner a cOpy of your response: The Chief Coroner may publish either or both in complete or redacted or summary form: He may send 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 time of your response, about release or the publication of your response by the Chief Coroner. Dated Sighed 28t February 2020 ukel kZhul %l Rachel Syed HM Assistant Coroner days the the duty the the

Responses

1 respondent

Bolton NHS Foundation Trust

NHS Trust

Indexed date: 23 Apr 2020 PDF

AI-classified response stance Action Taken

AI-generated response summary

• The Trust had already taken a number of actions related to the dispensing error, as detailed in a Serious Incident Review Report. • A prescribing guideline for colecalciferol in adult patients has been developed by the Clinical Pharmacy Team and specialist doctors.

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Dear Mrs Syed, Re:lrene Whittingham Re: Regulation 28 Report to Prevent Future Deaths am writing in response to your Regulation 28 Report to Prevent Future Deaths, issued following the Inquest touching the death of Irene Whittingham on 21 February 2020. May take this opportunity to extend my sincere condolences to the family of Mrs Whittingham for their loss and appreciate this will be a difficult time for the family: note that prior to Inquest hearing, you were provided with a Serious Incident Review Report confirming that a number of actions in relation to the dispensing error had already been taken by the Trust: Following receipt of the Regulation 28 Report;, the previous Chief Executive, Dr J Bene requested that the Chief Pharmacist and Deputy Medical Director review the matters detailed in your Report: am now in position to respond to your concerns as outlined in Section 5_ Section 5 (1) am very sorry to learn that during the course of establishing how Mrs Whittingham came about her death you heard evidence that there was a lack of clarity regarding the monitoring of Mrs Whittingham following the prescribing of a higher loading dose of the medication In order to address the concern; the attached prescribing guideline has been developed by the Clinical Pharmacy Team with contributions by the specialist doctors. The guideline will standardise and support the safe prescribing and administration of colecaliferol in adult patients. With regards to the prescribing of colecalciferol to patients under the age of 18 the Trust has guidance already in place and use. RECEIVED the

In addition to the actions already taken in the Serious Incident Report hope that my response has provided you and the family with the assurance that the Trust has taken additional appropriate action to mitigate the risk of future deaths. Please do not hesitate to contact me in the event you require any further assistance:

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Report details

Reference: 2020-0047
Date of report: 28 February 2020
Coroner: Rachel Syed
Coroner area: Manchester West

Responses identified

Responses identified 1 of 3

2 responses not yet linked

Organisations named in PFD reports are normally expected to respond within 56 days. Deadline: 24 Apr 2020 (estimated from the report date).

Sent to

EMIS

Royal Bolton Hospital

Wellsky

Source links

Judiciary.uk page → Report PDF →

Data: judiciary.uk.

Contains public sector information licensed under the Open Government Licence v3.0.