Source · Prevention of Future Deaths

Maureen Chatterley

Ref: 2015-0404 Date: 8 Oct 2015 Coroner: Alan Walsh Area: Manchester (West) Responses identified: 1 / 1 View PDF

Lack of investigation into alleged medication overdose and inadequate stock control for non-controlled drugs on wards, preventing verification of medication quantities and increasing risk of misuse or error.

Date 8 Oct 2015

56-day deadline 3 Dec 2015 est.

Responses identified 1 of 1

Hospital Death (Clinical Procedures and medical management) related deaths

Coroner's concerns

AI summary

View full coroner's concerns

1. During Inquest evidence was heard that There was no investigation by hospital in relation to the concerns expressed by the family in relation to the administration of an excess dose Of Lorazepam: There was no record of the stock of medication in relation to non-controlled drugs in the medication drawer allocated to a patient nor in and the medication cupboard on the ward, Accordingly medication could be removed the medication cupboard on the ward and used either for an elicit purpose or excess dosage without knowledge or record with reference to stock control: Evidence was given at Inquest that the pharmacist checked medications on ward on a daily basis but there was no check or record of the number of medications or the number of tablets in the allocated medication drawers or the cupboard on ward, particularly between the daily inspections by pharmacist: I request you to consider the above concerns and try out a review with regard to the following: The procedures in relation to the supply, security and safe keeping of medication on wards at the Royal Bolton Hospital: the keep the the from any the the the carry

Stock control and a record of medications both in the medication drawers allocated to individual patients and in cupboards on wards at the Royal Bolton Hospital to enable the medications and the quantities of medications to be identified and verified, both in the medication drawers and In cupboards on ward, at any point in time
iii. The evidence raised concerns that there is a risk that future deaths will occur unless action is taken to review the above issues:

Responses

1 respondent

Bolton NHS Trust NHS / Health Body

PDF

Action Planned

Bolton NHS Trust will introduce a new Wardex for pharmacists to record reviews and develop a local endorsement policy by February 2016. Safe and Secure Handling of Medicines Audits (Duthie) will be presented to Medicines Safety Group for discussion and agreement of action plans by December 2015. (AI summary)

View full response

Dear Mr Walsh Re:_Maureen Chatterley_Deceased 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 into the death of Maureen Chatterley held on 29 September 2015. May take this opportunity to extend my sincere condolences to the family of Mrs Chatterley for their loss On receipt of the Regulation 28, requested that the Chief Pharmacist and Medicines Safety Group review the matters detailed in your Report and am now in a position to respond to your concerns outlined in Section 5 (1) and (2) of Report as follows: - The Medicines Safety Group was created in 2013 with the purpose to develop, implement and maintain medication governance strategy and work plan within Bolton Foundation Trust around the safe and effective use and management of medicines The full terms of reference for this group are attached for your information: The procedures for security and safe keeping ofmedicines on wards is regulated by the standards set out in the Safe and Secure Handling of Medicines (2005), formally known as the Duthie Report (http Lwww dhsspsnigov uklthe-safe-and-secure-handling-of-medicines pdf). All clinical areas are audited quarterly, by pharmacy staff, against these standards and the results are discussed with the ward managers_ In addition to this the Medicines Safety Group has recently introduced additional measures to audit the security of medicines by introducing the NHS Protect's Medicines Security Ward/Department checklist These are completed by ward staff and collated for each division and the results and action plans discussed at the Medicines Safety Group. Copies of both audit forms have been included for information_ Local processes already in place that mitigate the risks related to medicines storage include the ordering of stock medicines by pharmacy staff for individual clinical areas_ This completed, as a minimum, weekly but is based on demand. the

While Safe and Secure Handling of Medicines (2005) deals in the main with medicines storage, the legal requirements for prescribing, administration and storage are regulated by the Medicines Act 1968 and the Misuse of Drugs Regulation 2001_ These pieces of legislation along with documents such as Safe and Secure Handling of Medicines (2005) inform the development of our Trust medicines policy (attached) As you be aware, the Misuse of Drug Regulations 2001, regulate the activities for certain medicines considered to be potentially harmful or dangerous and these are referred to as controlled drugs Under the various Schedules within the regulations only those medicines in Schedules or 2 e.g: morphine are subject to the requirement of running balances The Trust completes quarterly controlled drug audits against the regulations Many Trusts, including Bolton NHS Foundation Trust have introduced additional controls for medicines where local intelligence would suggest further restrictions beyond those required of the Medicines Act 1968 should be introduced: This is often referred to as restricted drugs_ Legally they cant be referred to as controlled drugs but restrictions o their use are similar to that imposed by the Misuse of Drugs Regulations 2001 _ The Medicines Safety Group has considered, in light of your concerns raised_ the inclusion of Lorazepam as a restricted drug However we feel adequate controls are in place, as outlined above, that do not warrant Lorazepam's inclusion to a restricted Iist: This decision has been taken in consideration of the restrictions balanced against the potential for missed doses, delays in administration and increase in nursing time in medicines administration. To facilitate the flow of patients through the organisation, Bolton NHS Foundation Trust has in place a one stop dispensing process This not only encourages the use of patients own drugs 'during admission but also encourages the dispensing of medicines to patients for individual use; _ therefore reducing the use of stock medicines. The process in pharmacy provides a permanent record in the patient's shared electronic record of date of dispensing, the quantity supplied and a date to review the stock levels and need for re-supply before the supply is exhausted. Where a patient brings their own medicines into the Trust; these are assessed for suitability of use (Appendix 16, Medicines Policy), The quantity brought in is recorded by pharmacy staff according to local policy DOP3Ob- Procedure for ward visit The above outlines the measures in place that the Medicines Safety Group believes will mitigate the matters of concern highlighted in your report, however in addition to the above the Group have also agreed the following actions and timescales: Action Target Date To be actioned bY_ Introduce new Wardex, which Dec 2015 Medicines Safety Group includes a section for pharmacists to record reviews of the wardex: This includes the clinical review and supply of _medicines Develop and implement a local Feb 2016 Medicines Safety Group endorsement policy by pharmacy staff of the Wardex, to include supply and quantity details Safe and Secure Handling of Dec 2015 Medicines Safety Group Medicines Audits (Duthie) to be presented to Medicines Safety Group for discussion and agreement of action plans am confident that the Trust has the necessary systems in place to ensure that medication which is kept on wards is stored safely and securely and that the Trust is able to verify at any point in time the medication stored in both stock cupboards and patient's medication drawers key will the

do hope that my response has provided you with the assurance that you and the family are looking for: If you need any further information, or if can be of any further assistarice please do not hesitate to contact me.

Report sections

Investigation and inquest

On 7th January 2015 I commenced an Investigation into the death of Maureen Chatterley (formerly known as Maureen Hinckley), 68 years, born 15t September 1946. The medical cause of death was 1a) Bronchopneumonia, 1b) Chronic Obstructive Pulmonary Disease, 2) Coronary Artery Atherosclerosis and infected right hip following fracture of neck of right femur: The conclusion of the Inquest was Maureen Chatterley died as a consequence of naturally occuring disease exacerbated by injuries sustained in an accidental fall and recognised complications arising from the treatment of her injuries:

Circumstances of the death

1. Maureen Chatterley died at the Royal Bolton Hospital, Minerva Road, Farnworth, Bolton on the 24t December 2014.
2. On the 27t August 2014 Mrs Chatterley had a fall at her home address ati sustaining a fracture of the neck of femur of the right hip: She was taken to the Royal Bolton Hospital, Bolton and on the 29t August 2014 she had surgery to repair the fracture: Mrs Chatterley was discharged hospital on the 1st September 2014 but she was re admitted to the hospital on the 4t October 2014 with a dislocated prosthesis of the right hip. The hip was manipulated to reduce the dislocation and Mrs Chatterley was discharged from the hospital on the 6th October 2014. On the gth October 2014 Mrs Chatterley suffered a further_dislocation of be from the the hip and she was admitted to Royal Bolton Hospital where she had surgery on the 9t October 2014 ad the 13t October 2014 when the prosthesis was removed: Mrs Chatterley had further surgical procedures on the 4t November 2014 and the 18* November 2014 to explore the hip and to carry out wash outs of puss and a haematoma:
3. From the 9th October 2014 until the 24t December 2014, when Mrs Chatterley died, she was treated with antibiotics and other medications including Loperamide for irritable bowel and Lorazepam for anxiety ad agitation: The dose of Lorazepam, which was commenced in December 2014, was prescribed as "PRN dose of 0. to a maximum Img in 24 hours"_ On the 14 December 2014 the family was concerned that 2 lmg of lorazepam was given as a single dose and the family informed Doctor and the nursing staff of their concerns in relation to the excess dose; The medication chart did not indicate that an excess dose f Lorazepam had been administered and the medication chart showed that the correct dose had been administered, However there was no investigation in relation to the family's concerns and the number of Lorazepam tablets in Mrs Chatterley's medication drawer was not checked at the time 5_ On the October 2014 Mrs Chatterley was transferred from Ward G4 to Ward G3, which is the Trauma Stabilisation Unit: Evidence was heard at the Inquest from a consultant nurse and from the ward manager in relation to medication prescribed to Mrs Chatterley whilst she was treated on Ward 63. The evidence referred to the fact that medications would be prescribed by a doctor ad obtained either from the pharmacy in the hospital or from stock of medication kept In cupboard on the ward: The medication would be requested and obtained by the by the nursing staff and the medication would be placed in a medication drawer allocated to the patient; The control of medication depended upon whether medication was a controlled drug or a non-controlled drug: In relation to non-controlled drugs, which included Lorazepam; a stock was kept In a cupboard on the ward and a nurse would obtain the medication from the stock in the cupboard and place the medication in the allocated medication drawer. The number of tablets placed in the allocated medication drawer are not counted, either individually or by the box, when are placed in the medication drawer and, on occasions, an unidentified number of tablets from opened boxes are placed in the drawer_ When Mrs Chatterley was prescribed Lorazepam the nurse obtained the Lorazepam tablets from the cupboard on the ward and placed an unknown number of tablets into the medication drawer allocated to Mrs Chatterley. However there was no record of the number of tablets placed_in the_medication drawer_allocated to_Mrs_Chatterley and there the Smg 14t the they was no stock record or control of the tablets remaining in the cupboard on ward. Accordingly the evidence confirmed that there was no record of the number of tablets in the medication drawer nor the cupboard on the ward at any point in time The ward manager gave evidence that there may be over medications supplied to patients on Ward G3 and it would be impossible to record of the number of tablets either in the medication drawers or the cupboard on the ward; The conclusions of the Inquest accepted that any excess dose of Lorazepam tablets did not play a part in the cause 0f death but it was accepted that; although there was no direct evidence of the administration of a excess dose, the concerns of the family had not been investigated and the administration of an excess dose of the medication could not be excluded;

Similar PFD reports

Shared signals

Related inquiry recommendations

Report details

Reference: 2015-0404
Date of report: 8 October 2015
Coroner: Alan Walsh
Coroner area: Manchester (West)

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: 3 Dec 2015 (estimated).

Sent to

Royal Bolton Hospital

Source links

Judiciary.uk page → Report PDF →

Data: judiciary.uk under OGL.