Source · Prevention of Future Deaths

Richard White

Ref: 2014-0085 Date: 28 Feb 2014 Coroner: Crispin Oliver Area: County Durham & Darlington Responses identified: 1 / 1 View PDF

Hope House lacked a formal, documented policy or protocol for medication administration, which was unknown to prescribers and not made available to staff.

Date 28 Feb 2014
56-day deadline 25 Apr 2014
Responses identified 1 of 1
Other related deaths

Coroner's concerns

AI summary
Hope House lacked a formal, documented policy or protocol for medication administration, which was unknown to prescribers and not made available to staff.
View full coroner's concerns
1) That the policy of Hope House with regard to the administration and holding by staff of medication was not made known to when she wrote the prescriptions;
2) That the policy was not provided in a protocol, or policy statement, to , or indeed, and
3) That no such protocol or policy statement was available.

Responses

1 respondent
700 Club2 Other
PDF
Noted

The 700 Club clarifies that it does not store or administer medication to clients, emphasizing that responsibility for safeguarding clients regarding medication lies with GPs. They will receive medication if handed to them, but will not return it without GP authorisation. (AI summary)

View full response
Dear Colleague am writing to your practice on behalf of the 700 Club to remove any ambiguity relating to the storage or administration of medication by our organization We do not; as a matter of policy, either store medication on the behalf of our clients, nor do we administer medication to clients. Prescriptions issued to our clients by your practice should take the above information into account, particularly if that client is vulnerable and there is a concern that the client may use that medication inappropriately (self-harm , selling on) : The responsibility for safeguarding clients in regard to prescribed medication lies with GP's. Occasionally a client will hand their medication to us because they feel tempted to take more than prescribed. If this does occur; we will receive it but will not return the medication to the client without the direct authority of the prescribing GP. Where that authority is provided, all of the surrendered medication will be handed back to the client; and not merely sufficient medication for any particular dose Or Again, reiterate; we do not administer: If the GP declines to give consent for all of the medication to be returned to the client then staff are instructed to return the medication to the nearest chemist and direct their client back to their GP. hope this letter clarifies our position as an organization.

Report sections

Investigation and inquest
On 14 June 2013 I commenced an investigation into the death of Richard Philip WHITE. The investigation concluded at the end of the inquest on 5th February 2014. The conclusion of the inquest was findings were that Mr White died at Darlington Memorial Hospital on 9th June 2013, having previously taken an overdose of cyclizine at 700 Club, Hope House, Darlington (“Hope House”) and the conclusion of the Inquest was that he had died as a result of misadventure.
Circumstances of the death
a. Richard White became a resident at Hope House on or about 15th or 16th May 2013. 700 Club is a charity which provides at Hope House, and St George`s Hall, supported hostel accommodation and support for vulnerable people with substance misuse issues or alcohol issues. On the 17th May Richard received a prescription for 21 cyclizine 50 mg tablets at Neasham Road Surgery, Darlington. On 6th June 2013 he received a prescription for 84 cyclizine 50 mg tablets plus 10 zopiclone 7.5 mg tablets at the same surgery. The zopiclone is a “sleeping pill” and the cyclizine was prescribed in relation to nausea. Richard had a history of previous attempts at self-harm, including one shortly before being admitted to Hope House, of which the staff there were aware at time the prescriptions were obtained.
b. At the appointment on 6th June 2013 with Mr White attended with his mother, and his Support Worker from 700 Club, During the Inquest gave evidence that she believed all of the medication she prescribed, cyclizine and zopiclone, would be kept secure by Hope House staff andthat had she known that this was not the case she would probably not have prescribed as much of the cyclizine as she did. gave evidence that he was concerned only about the “sleeping pills” (zopliclone) being looked after by Hope House staff.

gave evidence that she, like had the impression that the medication would be kept secure by Hope House. manager of Hope House, gave evidence that the policy of 700 Club is that medication is self-administered by the residents and only secured upon the request of the residents themselves and retained with their consent. She stated that she did not known where this policy was written down or kept.
c. After the appointment Mr White, his mother and attended the pharmacy where the medication was collected. took the zopiclone and placed it in the office of Hope House for Richard subsequently to access it. Mr White took possession of the cyclizine, from the outset. On 9th June 2013 Richard White presented to staff at Hope House and announced that he had taken 104 cyclizine tablets and 7 or 8 zopiclone tablets. In spite of the best endeavours of the staff and paramedics, he subsequently died as a result of cyclizine toxicity.

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Report details

Reference
2014-0085
Date of report
28 February 2014
Coroner
Crispin Oliver
Coroner area
County Durham & Darlington

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: 25 Apr 2014.

Sent to

700 Club

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