Jane Walker
PFD Report
All Responded
Ref: 2024-0137
Alcohol, drug and medication related deaths
Other related deaths
Wales prevention of future deaths reports (2019 onwards)
All 1 response received
· Deadline: 8 May 2024
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Source: Courts and Tribunals Judiciary
Coroner’s Concerns
Coroner's Office, Shirehall Street, Caernarfon
Jane was administered morphine for pain relief at the slip way by the paramedics. Administering such opioid medication takes time in that a cannula must first be inserted and once administered the morphine can take up to 15 minutes to be effective.
Evidence was heard at the Inquest that there are alternative analgesics which can be administered much more quickly, have a much quicker impact and can be easier to remove when required. Example of such is mucosal fentanyl lozenge. This can be administered by placing the lozenge (on a stick) into the patient’s mouth, which takes effect very quickly and which can be removed quickly if required. It can be considered a safe and rapid method of delivering pre-hospital analgesia and is used by the military. It is not, however, available to paramedics.
I am concerned that the unavailability of such analgesics to paramedics (in England as well as Wales) to assist patients who require immediate pain relief in the context of it reducing stress on the body, providing easier and potentially faster extrication and patient handling, and improving breathing, where time is of the essence for medical treatment, to reflect a risk of deaths into the future.
Pursuant to controlled drug legislation paramedics are not currently permitted to administer such analgesics. Whilst matters of health are devolved to Wales, controlled drug legislation in this context is not a devolved matter to Wales, hence this Report to the Home Secretary. I am aware that The Medicines Act 1968 and/or other controlled drug legislation would require amendment to allow paramedics to administer such analgesia.
Jane was administered morphine for pain relief at the slip way by the paramedics. Administering such opioid medication takes time in that a cannula must first be inserted and once administered the morphine can take up to 15 minutes to be effective.
Evidence was heard at the Inquest that there are alternative analgesics which can be administered much more quickly, have a much quicker impact and can be easier to remove when required. Example of such is mucosal fentanyl lozenge. This can be administered by placing the lozenge (on a stick) into the patient’s mouth, which takes effect very quickly and which can be removed quickly if required. It can be considered a safe and rapid method of delivering pre-hospital analgesia and is used by the military. It is not, however, available to paramedics.
I am concerned that the unavailability of such analgesics to paramedics (in England as well as Wales) to assist patients who require immediate pain relief in the context of it reducing stress on the body, providing easier and potentially faster extrication and patient handling, and improving breathing, where time is of the essence for medical treatment, to reflect a risk of deaths into the future.
Pursuant to controlled drug legislation paramedics are not currently permitted to administer such analgesics. Whilst matters of health are devolved to Wales, controlled drug legislation in this context is not a devolved matter to Wales, hence this Report to the Home Secretary. I am aware that The Medicines Act 1968 and/or other controlled drug legislation would require amendment to allow paramedics to administer such analgesia.
Responses
Response received
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Dear Ms Robertson
Thank you for your Prevention of Future Deaths report of 13 March concerning the tragic death of Jane Walker who died after a collision with a jet ski while on a rigid inflatable boat. In the report you recommend that paramedics should be provided with powers to administer mucosal fentanyl lozenges to ensure fast acting pain relief.
You are receiving a response from an official in accordance with procedures for handling correspondence during the pre-election period.
I understand that evidence heard at the inquest included detail about a mucosal fentanyl lozenge as an alternative, easier to remove and faster-acting analgesic to that received by Ms Walker (who was administered morphine via a cannula, which can take 15 minutes to be effective). At the time of Ms Walker’s death paramedics did not have the authority to administer that form of pain relief.
Your recommendation mirrors two recommendations made in the report Manchester Arena Inquiry Volume 2: Emergency Response, which are as follows:
Recommendation 118: The Department of Health and Social Care and the Medicines and Healthcare products Regulatory Agency (MHRA) should consider urgently whether the regulatory regime should be altered to enable analgesia, such as fentanyl lozenges or sufentanil sublingual tablets, to be given by paramedics to injured persons.
Recommendation 119: If the decision is that the regulatory regime should be altered in this way, the National Ambulance Resilience Unit should consider urgently whether the use of such analgesia should be rolled out to all Hazardous Area Response Team and other specialist operatives, as part of their basic equipment, and to paramedics more generally.
The Manchester Arena Inquiry reports are available at the following link: Manchester Arena Inquiry reports - GOV.UK (www.gov.uk)
Official-Sensitive
The NHS England Task & Finish Group on Analgesia was established to consider these two recommendations. This comprises civilian and military clinical representatives, academics, representatives of the Faculty of Pre-Hospital Care, the College of Paramedics, ambulance pharmacists and government officials. This group works closely with colleagues in the Devolved Administrations to ensure any learning is shared and can be considered for use in the respective countries. Evidence gathering and evaluation are ongoing. The group has been provided with a copy of your letter for their reference.
Once this group has reported its conclusions, these and any recommendations about paramedics and the administration of fentanyl will be considered by a future government.
Thank you for your Prevention of Future Deaths report of 13 March concerning the tragic death of Jane Walker who died after a collision with a jet ski while on a rigid inflatable boat. In the report you recommend that paramedics should be provided with powers to administer mucosal fentanyl lozenges to ensure fast acting pain relief.
You are receiving a response from an official in accordance with procedures for handling correspondence during the pre-election period.
I understand that evidence heard at the inquest included detail about a mucosal fentanyl lozenge as an alternative, easier to remove and faster-acting analgesic to that received by Ms Walker (who was administered morphine via a cannula, which can take 15 minutes to be effective). At the time of Ms Walker’s death paramedics did not have the authority to administer that form of pain relief.
Your recommendation mirrors two recommendations made in the report Manchester Arena Inquiry Volume 2: Emergency Response, which are as follows:
Recommendation 118: The Department of Health and Social Care and the Medicines and Healthcare products Regulatory Agency (MHRA) should consider urgently whether the regulatory regime should be altered to enable analgesia, such as fentanyl lozenges or sufentanil sublingual tablets, to be given by paramedics to injured persons.
Recommendation 119: If the decision is that the regulatory regime should be altered in this way, the National Ambulance Resilience Unit should consider urgently whether the use of such analgesia should be rolled out to all Hazardous Area Response Team and other specialist operatives, as part of their basic equipment, and to paramedics more generally.
The Manchester Arena Inquiry reports are available at the following link: Manchester Arena Inquiry reports - GOV.UK (www.gov.uk)
Official-Sensitive
The NHS England Task & Finish Group on Analgesia was established to consider these two recommendations. This comprises civilian and military clinical representatives, academics, representatives of the Faculty of Pre-Hospital Care, the College of Paramedics, ambulance pharmacists and government officials. This group works closely with colleagues in the Devolved Administrations to ensure any learning is shared and can be considered for use in the respective countries. Evidence gathering and evaluation are ongoing. The group has been provided with a copy of your letter for their reference.
Once this group has reported its conclusions, these and any recommendations about paramedics and the administration of fentanyl will be considered by a future government.
Report Sections
Investigation and Inquest
On 11 August 2020 an investigation was commenced into the death of Jane Walker (DOB 3 April 1968) who died on 8 August 2020. The investigation concluded at the end of the inquest on 13 March 2024. The conclusion of the inquest was accident.
Circumstances of the Death
The circumstances of the death are as follows :-
On 8 August 2020 Jane Walker was a passenger on a rigid inflatable boat on the Menai Straits when a collision occurred between the rigid inflatable boat and a jet ski. Jane suffered significant internal injuries, was attended to by paramedics at the slip way and then conveyed to hospital, where she later died. The circumstances were investigated by the Marine Accident Investigation Branch.
On 8 August 2020 Jane Walker was a passenger on a rigid inflatable boat on the Menai Straits when a collision occurred between the rigid inflatable boat and a jet ski. Jane suffered significant internal injuries, was attended to by paramedics at the slip way and then conveyed to hospital, where she later died. The circumstances were investigated by the Marine Accident Investigation Branch.
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.