Source · Prevention of Future Deaths

Craig Hamilton

Ref: 2017-0197 Date: 13 Jun 2017 Coroner: Nicola Mundy Area: South Yorkshire (East) Responses identified: 1 / 1 View PDF

A lack of clear procedures to manage patients routinely obtaining or exceeding prescribed medication dosages, or to discuss alternative pain management, poses significant risks.

Date 13 Jun 2017

56-day deadline 6 Oct 2017 est.

Responses identified 1 of 1

Community health care and emergency services related deaths

Coroner's concerns

AI summary

A lack of clear procedures to manage patients routinely obtaining or exceeding prescribed medication dosages, or to discuss alternative pain management, poses significant risks.

View full coroner's concerns

(1) Absence of clear procedures to manage patients who routinely access larger amounts of medication than actually prescribed.

(2) Absence of clear procedures to monitor and manage patients who endeavour to obtain repeat prescriptions such that it takes them beyond the prescribed dosages_ (3) Absence of clear procedures to fully explore drug regimes alternative forms of pain management at annual medication reviews_ (4) Consideration for improved systems for discussing with patients the implications of them attempting to exceed prescribed dosages and recording that such discussions have taken place. Coroner'$ Court and Office; Doncaster Crown Court; Collcge Road, Doncaster, DNI 3HS Tel 01302 737135 Fax 01302 736365 drug self day: and

Responses

1 respondent

Manor Field Surgery Other

1 Aug 2017 PDF

Action Taken

The practice identified patients prescribed tramadol and other medicines with the potential for self-harm and changed all electronic prescriptions to paper format for review. They have changed their policy for repeat prescribing of all medication and created an amended 'Repeat Prescribing Policy and Procedure' and 'Acute Prescribing Protocol'. (AI summary)

View full response

Dear Ms Mundy, Re: Craig Stuart HAMILTON (Deceased) DOB: 07.08.1980 DOD: 08.12.2016 Further to your letter and report in respect of the above named. please find our response and actions as below: We took immediate action on the afternoon of the inquest to identify the patients prescribed tramadol and extended the search to other medicines with the potential for self- harm. All electronic prescriptions were changed to paper format and passed t0 the doctors for review before signing: All names of patients identified were passed to one of the partners to perform review of the computer notes and make recommendation. The inspection included the indication for the medicine the recommended dose on the prescription the recent historical issue pattern The recommended outcome was one of the following: Immediate action to contact the patient Request for early review No change in current prescribing We have met several times as partners. We have sought advice from the Clinical Commissioning Group, particularly the Medicines Management Team. We asked the Drugs and Alcohol Team for advice and assistance in dealing with more difficult cases. Our local pharmacist was alerted to the problem and invited to provide information on prescriptions his team thought problematic. The issue has been escalated to significant event through the national reporting system, 'STEIS (Executive Information System)' , via the local Clinical Commissioning Group This report will be copied to them and contains extra information to allow them to complete their being

proforma The search showed that 79 of our 90 patients taking tramadol were not abusing the Action has been taken to limit the potential over-users by calling them in for early review: We have discovered that our procedures for issue and review of medication were not satisfactory_ We have completed thorough review of the medication ordering/ review procedure and found two problems that may have led to the death: Our receptionists were skipping a computer dialog box reminding them of early issue of medication Our doctors had insufficient time in the consultation for review of complex problems Since this incident our practice attitude has changed: We have changed our policy for repeat prescribing of all medication, not just tramadol_ We enclose an amended 'Repeat Prescribing Policy and Procedure' and Acute Prescibing Protocol' . There are significant changes from our previous policy: I draw your attention to the specific instruction on the box and to changes in the way the GP consultations are structured in time and process. The enclosed protocols have been examined by GP partners and practice manager: am to explain to all staff in the practice, in protected time, the changes within 10 hope the enhancements cover your Matters of Concern_

Report sections

Investigation and inquest

On 14/12/2016 commenced an investigation into the death of Craig Stuart Hamilton, 36 The investigation concluded at the end of the inquest on 13 June 201 The conclusion of the inquest was Prescribed related death. Craig Stuart Hamilton died at Maltby on 8 December 2016 after ingesting excess Tramadol medication in an attempt to relieve his chronic pain which unintentionally led to his death from acute tramadol toxicity

Circumstances of the death

Mr Hamilton suffered a serious assault in 2009 leading to permanent and serious damage to his right leg: Part of the residual problems included chronic pain for which he received Tramadol from 2009 until the time of his death. It became clear from the evidence heard that despite the prescribed rate (which was the maximum recommended by BNF for effective pain relief) in 2009, Mr Hamilton had effectively medicated to the extent that he was taking almost double that dose on a regular basis from 2009 until the time of his death Mr Hamilton died from Tramadol toxicity after taking excess amounts with the intention of controlling the pain sufficient that he could sleep during the night before working the next He did not take excess amounts with the intention of causing any self harm or ending his life

Action should be taken

In my opinion action should be taken to prevent future deaths and believe you The Practice Manager; Manor Field Surgery have the power to take such action:

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Report details

Reference: 2017-0197
Date of report: 13 June 2017
Coroner: Nicola Mundy
Coroner area: South Yorkshire (East)

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: 6 Oct 2017 (estimated).

Sent to

Manor Field Surgery

Source links

Judiciary.uk page → Report PDF →

Data: judiciary.uk under OGL.