Source · Prevention of Future Deaths

Jonathan Earp

Ref: 2018-0135 Date: 8 May 2018 Coroner: Caroline Saunders Area: Gloucestershire Responses identified: 1 / 1 View PDF

Inadequate management of prescribed Fentanyl patches meant 'unspent' medication was not accounted for, and staff failed to consider the cumulative effect of Fentanyl and suspected illicit drug use.

Date 8 May 2018

56-day deadline 26 Aug 2018 est.

Responses identified 1 of 1

Hospital Death (Clinical Procedures and medical management) related deaths

Coroner's concerns

AI summary

Inadequate management of prescribed Fentanyl patches meant 'unspent' medication was not accounted for, and staff failed to consider the cumulative effect of Fentanyl and suspected illicit drug use.

View full coroner's concerns

In the circumstances it is my statutory to report to you. heard during the inquest that Mr Earp had been prescribed Fentanyl which was administered by way of transdermal patches_ Mr Earp repeatedly requested additional patches however there was no evidence that all of the "unspent" patches had been returned to the nursing staff or appropriately discarded: The clinical staff believed that Mr Earp was accessing illicit drugs when he left the ward, however there was no evidence that staff considered that he may have been taking additional Fentanyl and illicit medication, and the effect this could have would ask that consideration is given to providing staff with guidance on how to manage the administration and provision of prescribed drugs when the patient is also accessing non-prescribed potentially illicit drugs Gloucestershire Coroner'$ Court; Corinium Avenue Barnwood, Gloucester, GL4 3DJ Tel 01452 305661 Fax 01452 412618 duty

Responses

1 respondent

Gloucestershire Hospitals NHS Trust NHS / Health Body

8 May 2018 PDF

Action Taken

The Trust reviewed the circumstances of fentanyl administration, discussed the case with ward staff and presented it to the Senior Nurse and Midwifery Committee. An action plan confirms work undertaken and ongoing as a result of the death, with oversight from the Trust Quality Delivery Group. (AI summary)

View full response

Dear Ms Saunders TheLate Mr_Jonathan am in response to the letter dated 8 May 2018 from your Officer enclosing the Regulation 28 Report to prevent future deaths_ The Trust has noted your outstanding concerns as described in paragraph 5 of your Report: Following the inquest; the Trust has further reviewed the circumstances of the administration of fentanyl to Mr Earp. Under the direction of Mr Steve Hams, Director of Quality and Chief Nurse, this case has been discussed with the ward staff who looked after Mr Earp, and has been presented to the Senior Nurse and Midwifery Committee_ The enclosed Action Plan confirms work which the Trust has undertaken, and continues to work on, as a result of Mr Earp's death. The Trust Quality Delivery Group will maintain oversight of these actions and ensure are being delivered. hope this is helpful. Please do not hesitate to contact me if you require further information

Report sections

Investigation and inquest

On the 21/7/2017 | commenced an investigation into the death of Jonathan EARP_ The investigation concluded at the end of the inquest on 25/4/18 The conclusion of the inquest was a Drug Related Death: The medical cause of death was determined to be: 1a The combined toxic effects of Alcohol, Diazepam , Pregabalin, Fentanyl, cocaine, Zopiclone_ Mirtazepine and Morphine

Circumstances of the death

Jonathan Earp died at 08:15 on 10/7/17 at Gloucester Royal Hospital from the effects of prescribed and non-prescribed drugs

Action should be taken

In my opinion action should be taken to prevent future deaths and believe you have the power to take such action:

Similar PFD reports

Shared signals

Related inquiry recommendations

Report details

Reference: 2018-0135
Date of report: 8 May 2018
Coroner: Caroline Saunders
Coroner area: Gloucestershire

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: 26 Aug 2018 (estimated).

Sent to

Gloucestershire Hospitals NHS Trust

Source links

Judiciary.uk page → Report PDF →

Data: judiciary.uk under OGL.