Source · Prevention of Future Deaths

Deborah Chapman

Ref: 2019-0280 Date: 1 Aug 2019 Coroner: Adrian Farrow Area: Manchester (South) 1 response identified · 1 indexed addressee View PDF

AI-generated concerns summaryThe coroner identified gaps in the medical centre's inquiry and recording of a patient's illicit drug misuse, which prevented an informed risk assessment for prescribing pregabalin and oxycodone given potential interactions.

Date 1 Aug 2019
56-day deadline 13 Dec 2019 est. estimated from the Judiciary.uk publication date
Responses identified 1 of 1
Alcohol, drug and medication related deaths Community health care and emergency services related deaths

Coroner's concerns

AI summary
The coroner identified gaps in the medical centre's inquiry and recording of a patient's illicit drug misuse, which prevented an informed risk assessment for prescribing pregabalin and oxycodone given potential interactions.
View full coroner's concerns
In the circumstances it is my statutory to report to you: heard evidence from representing the West Timperley Medical Centre: He acknowledged that the known side effects of both pregabalin and oxycodone, both individually and concomitantly, presented risk of having depressive effect on the respiratory system_ He also acknowledged that Ms Chapman'$ COPD represented an underlying compromise of her respiratory system. The evidence heard from the records held at the medical centre did not reveal the extent to which enquiry was made of Ms Chapman as to her current misuse of illicit drugs either on the occasion of her re joining the medical practice as a patient in July 2018 or at subsequent consultations. There were clear signs of a dependence on the prescribed opiate drugs and the medical records equally revealed long-term illicit opiate misuse_
3. The evidence heard from the medical records held at the medical centre did not reveal, beyond the admitted dependence on the prescribed medication, what enquiry had been made from Ms Chapman in relation to her continued misuse of illicit or her response to those enquiries: In the absence of that information, it was not possible, from the medical records, to ascertain what level of risk the continued illicit misuse of opiates posed to Ms Chapman and therefore, whether, on an informed basis, pregabalin and oxycodone were appropriate prescriptions 5 . Furthermore, the evidence did not reveal any system in place at the West Timperley Medical Centre to ensure that the information about illicit misuse is obtained and recorded from patients in order to ensure that an informed assessment of the risks of the concomitant use prescribed and illicit drugs could be made and reviewed:

Responses

1 respondent

West Timperley Medical Centre

Other
Indexed date: 18 Sep 2019 PDF
AI-classified response stance Action Taken
AI-generated response summary

• The Primary Care Team discussed Mrs Chapman's death, emphasising the need to maintain up-to-date records of all illicit drug use. • The medical centre conducts regular clinical system searches to identify patients prescribed opiate analgesia or Pregabalin with a history of misuse. • Identified patients are being contacted to update their current illicit drug use records.

View full response
Dear Sir Re: Mrs Deborah Chapman (Dcccased) DOB: 03-Jun-|964 NHS No: 476 227 2787 Further I0 your Regulation 28 Report dated /" August 20/9, hereby delail the actions taken by West Timperley Medical Centre. In the first instonce, Chopman'$ death was discussed in 9 Primary Care Team In particular; thc need t0 ensure we havc an up l0 dale record of all illicit usC was emphasised and @ reminder of the that @ record of intravcnous abusc having been stopped does not mean (hat all illicit use has been stopped. We have in place a regular search of our clinicel syslem to identify palients that ore regular opiale analgesia and who have a past hislory of misuse_ A similar search has been undertaken for those patients regular Pregabalin. The searches have identified 16 paticnts opiale analgesia with a hislory ol misuse and patients regular Pregabalin with 0 history of past misuse: We pre currently contacting those patients t0 ensure that we have an UP [0 dale record of their current illicit usC. Dtis our intention t0 conlact all GP"s in the Trafford CCG area &d outline Ihe concems rised in your Regulation 28 our response t0 those concems: trust the above actions constitule an adequate response t0 your Regulation 28 Report Youcs faithfully Scpior Paritner West Timberley Medical Centre Mrs Meeting: drug fact drug drug pul taking drug taking taking regular drug taking drug drug Repon and

Report sections

Investigation and inquest
On 20t 2019,an inquest was opened into the death of Deborah Chapman who died on 3r March 2019a Altrincham, WA14 4LN, at the age of 54 years. The investigation concluded with an inquest which heard on 31s July 2019 and which concluded with a Conclusion to the effect that Ms Chapman died as a consequence of a combination of prescribed and illicit drugs:
Action should be taken
In my opinion action should be taken to prevent future deaths and believe you and your organisation have the power to take such action duty any drugs drug

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Shared signals

Report details

Reference
2019-0280
Date of report
1 August 2019
Coroner
Adrian Farrow
Coroner area
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: 13 Dec 2019 (estimated from the Judiciary.uk publication date).

Sent to

West Timperley Medical Centre

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