Teresa Bennett
PFD Report
All Responded
Ref: 2024-0081
Alcohol, drug and medication related deaths
Wales prevention of future deaths reports (2019 onwards)
All 1 response received
· Deadline: 10 Apr 2024
Response Status
Responses
1 of 1
56-Day Deadline
10 Apr 2024
All responses received
About PFD responses
Organisations named in PFD reports must respond within 56 days explaining what actions they are taking.
Source: Courts and Tribunals Judiciary
Coroner’s Concerns
(1) Lack of compliance with the target of 12-15 monthly medication reviews in Health Board managed GP practices.
(2) No standard practice for medication reviews leading to a lack assurance that all pertinent matters will be covered and the approach varying between clinicians and practices.
(3) The risk of inadvertent overdose in individuals like Ms Bennett, where medication that can cause e.g drowsiness and fatigue, is prescribed alongside strong opiates and other drugs that have the ability to depress the central nervous system when such medicines are prescribed without regular reviews nor specific advice in respect of the associated risks issued to patients e.g in Ms Bennett’s case, she was instructed to simply “remove old patch and apply new patch every 72 hours”
(2) No standard practice for medication reviews leading to a lack assurance that all pertinent matters will be covered and the approach varying between clinicians and practices.
(3) The risk of inadvertent overdose in individuals like Ms Bennett, where medication that can cause e.g drowsiness and fatigue, is prescribed alongside strong opiates and other drugs that have the ability to depress the central nervous system when such medicines are prescribed without regular reviews nor specific advice in respect of the associated risks issued to patients e.g in Ms Bennett’s case, she was instructed to simply “remove old patch and apply new patch every 72 hours”
Responses
Betsi Cadwaladr University Health Board has commenced benchmarking for medication reviews, is implementing a new Standard Operating Procedure for medication reviews, and from May 2024, will add an opioid leaflet to the clinical system for patients. A mandatory medicines management Local Enhanced Service, including opioid prescribing, is running from April 2024.
AI summary
View full response
Dear Ms Riley,
REGULATION 28 REPORT TO PREVENT FUTURE DEATHS Teresa Ann Bennett
I write in response to the Regulation 28 Report to Prevent Future Deaths dated 14 February 2024, issued by yourself to Betsi Cadwaladr University Health Board, following the inquest into the death of Teresa Ann Bennett.
I would like to begin by offering my deepest condolences to the family and friends of Ms Bennett.
In the notice, you highlighted your concerns regarding:
The lack of compliance with the target of 12-15 monthly medication reviews in Health Board managed GP practices; The absence of a standard practice for medication reviews leading to a lack assurance that all pertinent matters will be covered and the approach varying between clinicians and practices; The risk of inadvertent overdose in individuals like Ms Bennett, where medication that can cause e.g. drowsiness and fatigue, is prescribed alongside strong opiates and other drugs that have the ability to depress the central nervous system when such medicines are prescribed without regular reviews nor specific advice in respect of the associated risks issued to patients.
In response to these concerns, I asked our primary care teams to review and submit improvement actions which are detailed below.
We have commenced benchmarking work on 21 February 2024 for all Health Board managed practices to identify all patients on regular repeat medication who have not got a medication review documented in the notes in the last 12-15 months. This work will be completed by 31 May 2024. These patients will then be risk stratified for medication review. This will occur parallel to implementing new procedures as outlined below.
Dyddiad / Date: 10 April 2024 Sarah Riley HM Assistant Coroner North Wales (West) Coroner's Office Coroner's Office Shirehall Street CAERNARFON Gwynedd, LL55 1SH Bloc 5, Llys Carlton, Parc Busnes Llanelwy, Llanelwy, LL17 0JG
---------------------------------- Block 5, Carlton Court, St Asaph Business Park, St Asaph, LL17 0JG
A pan Health Board policy is now being developed to outline the standards for medication review within our managed practices. This will be completed by 30 June 2024.
In order to ensure we review outstanding patients on repeat medication the policy will risk score patients on a priority level from 1 to 4 and outline exactly who will be included in each level. For example, Level 1 risk patients will be those >75 on polypharmacy, patients on high dose opiates, down to level 4 patients who are under 50 and on less than 4 medications.
Standard Operating Procedures will then be put in place at each practice to add the detail of responsibility and governance of the process; this will differ at each practice due to staffing skill mix.
Practices will report their progress against medication review targets at assurance meetings that will be held regularly (every 2 months). These will be reported at a newly formed managed practice Quality and Governance Group which will cover all North Wales services.
Addressing the concerns regards patient information and their awareness of risks, additional warnings are included on pharmacy labels on the outside of medication boxes, which reference the risks of drowsiness. In addition, patient information leaflets are included in every box which outlines what to do in various scenarios e.g., increased drowsiness, if patches no longer giving pain relief, and if a patch falls off.
Health Board Managed Practices will, from 01 May 2024, add the Faculty of Pain Medicine opioid leaflet onto the clinical system. This will be printed and given to patients on opioids at their medication review, or when opioids are started or doses changed. A copy of this leaflet is attached as an appendix.
Learning will be shared with independent contractor GP practices via the primary care governance processes.
Our medicines management Local Enhanced Service (LES) running from April 2024 - March 2025 will contain two sections on opioid prescribing. This LES is applicable for all GP practices within the Health Board area and is mandatory.
We would be happy to meet with you further and discuss our plans in more detail, or provide further information and assurance should that be helpful.
Once again, I offer my deepest condolences to the family and friends of Ms Bennett for their loss and I reiterate my sincere apologies to them for the concerns identified at inquest.
REGULATION 28 REPORT TO PREVENT FUTURE DEATHS Teresa Ann Bennett
I write in response to the Regulation 28 Report to Prevent Future Deaths dated 14 February 2024, issued by yourself to Betsi Cadwaladr University Health Board, following the inquest into the death of Teresa Ann Bennett.
I would like to begin by offering my deepest condolences to the family and friends of Ms Bennett.
In the notice, you highlighted your concerns regarding:
The lack of compliance with the target of 12-15 monthly medication reviews in Health Board managed GP practices; The absence of a standard practice for medication reviews leading to a lack assurance that all pertinent matters will be covered and the approach varying between clinicians and practices; The risk of inadvertent overdose in individuals like Ms Bennett, where medication that can cause e.g. drowsiness and fatigue, is prescribed alongside strong opiates and other drugs that have the ability to depress the central nervous system when such medicines are prescribed without regular reviews nor specific advice in respect of the associated risks issued to patients.
In response to these concerns, I asked our primary care teams to review and submit improvement actions which are detailed below.
We have commenced benchmarking work on 21 February 2024 for all Health Board managed practices to identify all patients on regular repeat medication who have not got a medication review documented in the notes in the last 12-15 months. This work will be completed by 31 May 2024. These patients will then be risk stratified for medication review. This will occur parallel to implementing new procedures as outlined below.
Dyddiad / Date: 10 April 2024 Sarah Riley HM Assistant Coroner North Wales (West) Coroner's Office Coroner's Office Shirehall Street CAERNARFON Gwynedd, LL55 1SH Bloc 5, Llys Carlton, Parc Busnes Llanelwy, Llanelwy, LL17 0JG
---------------------------------- Block 5, Carlton Court, St Asaph Business Park, St Asaph, LL17 0JG
A pan Health Board policy is now being developed to outline the standards for medication review within our managed practices. This will be completed by 30 June 2024.
In order to ensure we review outstanding patients on repeat medication the policy will risk score patients on a priority level from 1 to 4 and outline exactly who will be included in each level. For example, Level 1 risk patients will be those >75 on polypharmacy, patients on high dose opiates, down to level 4 patients who are under 50 and on less than 4 medications.
Standard Operating Procedures will then be put in place at each practice to add the detail of responsibility and governance of the process; this will differ at each practice due to staffing skill mix.
Practices will report their progress against medication review targets at assurance meetings that will be held regularly (every 2 months). These will be reported at a newly formed managed practice Quality and Governance Group which will cover all North Wales services.
Addressing the concerns regards patient information and their awareness of risks, additional warnings are included on pharmacy labels on the outside of medication boxes, which reference the risks of drowsiness. In addition, patient information leaflets are included in every box which outlines what to do in various scenarios e.g., increased drowsiness, if patches no longer giving pain relief, and if a patch falls off.
Health Board Managed Practices will, from 01 May 2024, add the Faculty of Pain Medicine opioid leaflet onto the clinical system. This will be printed and given to patients on opioids at their medication review, or when opioids are started or doses changed. A copy of this leaflet is attached as an appendix.
Learning will be shared with independent contractor GP practices via the primary care governance processes.
Our medicines management Local Enhanced Service (LES) running from April 2024 - March 2025 will contain two sections on opioid prescribing. This LES is applicable for all GP practices within the Health Board area and is mandatory.
We would be happy to meet with you further and discuss our plans in more detail, or provide further information and assurance should that be helpful.
Once again, I offer my deepest condolences to the family and friends of Ms Bennett for their loss and I reiterate my sincere apologies to them for the concerns identified at inquest.
Report Sections
Investigation and Inquest
On the 8th December 2021, I commenced an investigation into the death of Ms Teresa Ann Bennett. The investigation concluded at the end of the inquest on the 9th February 2024.
Circumstances of the Death
Teresa Ann Bennett was a female, aged 57 at the time of her death. She had a number of significant comorbidities, and her case was unusual and complex. Mrs Bennett was prescribed and taking 13 separate medications at the time of her death, seven of which, including Fentanyl, had side effects linked to the central nervous system.
On the evening of the 30th November 2021, Ms Bennett’s son had seen her taking her medication as usual. Ms Bennett retired to bed around 30 minutes or so later. Around 3am on the 1st December 2021, Ms Bennett’s son found her asleep on the bedroom floor, appearing to have fallen from the bed. He helped her back to bed, ensuring she was comfortable, and left the room. At around 12pm on the 1st December 2021, Ms Bennett’s son noticed that she was still in bed and it became apparent that she had passed away. Ms Bennett’s son called the Emergency Services who attended and declared life extinct at 13.12pm.
A post mortem examination was ordered and the cause of death recorded at inquest was: 1a Multi organ failure 1b Fatty liver and combined drug toxicity
Mrs Bennett was prescribed micrograms of Fentanyl over 72 hours. This was provided as one patch and one patch, both to be used at same time and identifiable as being different in size. At post mortem, Matrifen (a form of fentanyl) patches were found on Ms Bennett’s legs, two on the left and one on the right. This would amount to a dose of
. This dose differs from what was prescribed and issued by the GP and correlates to a significant dose increase of over 72 hours, which is the equivalent of of morphine daily. The toxicological analysis showed multiple drugs with Fentanyl being within the toxic and fatal range.
It was recognised that Ms Bennett was prescribed a high dose of Fentanyl. Ms Bennett had been on a dose of / hr over 72 hours since 2008. The instructions recorded in the GP notes simply stated ‘remove old patch and apply new patch every 72 hours’ There was no evidence to suggest that Ms Bennett was not compliant with her medications. There was no evidence of ordering discrepancies, no stockpiling or using the medication incorrectly and there was nothing to indicate that Ms Bennett raised any concerns or mentioned any difficulties with the medication she was taking.
The prescription dose of Fentanyl had not changed since 2008 and the directions for use had not changed. There was no evidence that the application of Fentanyl patches resulting in a dose of micrograms was intentional. I found that Ms Bennett had inadvertently overdosed on Fentanyl, and that, in combination with other medicines, a number of which possessed the ability to depress the nervous system, led to her death.
Ms Benett’s GP practice was managed directly by the Health Board. It is Standard Health Board practice for medication reviews to be completed at 12-15 month intervals but, in Ms Bennett’s case, that target had not been met on a single occasion since 2015. There is a lack of monitoring and no standardised process for medication reviews in the Health Board managed practices.
There is a risk of harm if medication reviews are not undertaken at regular intervals, including a risk of death in complex cases, like Ms Bennett’s. There is also a risk of harm or death if all pertinent matters are not considered during the reviews. At inquest, the Health Board produced an improvement plan that, inter alia, included actions to address the lack of compliance with the 12-15 monthly medication reviews. The target completion date for addressing the lack of compliance with the 12-15 monthly medication reviews is the 31st May 2025, a further 15 months from now. This, in my view, is not quick enough and I am concerned that future deaths may occur.
On the evening of the 30th November 2021, Ms Bennett’s son had seen her taking her medication as usual. Ms Bennett retired to bed around 30 minutes or so later. Around 3am on the 1st December 2021, Ms Bennett’s son found her asleep on the bedroom floor, appearing to have fallen from the bed. He helped her back to bed, ensuring she was comfortable, and left the room. At around 12pm on the 1st December 2021, Ms Bennett’s son noticed that she was still in bed and it became apparent that she had passed away. Ms Bennett’s son called the Emergency Services who attended and declared life extinct at 13.12pm.
A post mortem examination was ordered and the cause of death recorded at inquest was: 1a Multi organ failure 1b Fatty liver and combined drug toxicity
Mrs Bennett was prescribed micrograms of Fentanyl over 72 hours. This was provided as one patch and one patch, both to be used at same time and identifiable as being different in size. At post mortem, Matrifen (a form of fentanyl) patches were found on Ms Bennett’s legs, two on the left and one on the right. This would amount to a dose of
. This dose differs from what was prescribed and issued by the GP and correlates to a significant dose increase of over 72 hours, which is the equivalent of of morphine daily. The toxicological analysis showed multiple drugs with Fentanyl being within the toxic and fatal range.
It was recognised that Ms Bennett was prescribed a high dose of Fentanyl. Ms Bennett had been on a dose of / hr over 72 hours since 2008. The instructions recorded in the GP notes simply stated ‘remove old patch and apply new patch every 72 hours’ There was no evidence to suggest that Ms Bennett was not compliant with her medications. There was no evidence of ordering discrepancies, no stockpiling or using the medication incorrectly and there was nothing to indicate that Ms Bennett raised any concerns or mentioned any difficulties with the medication she was taking.
The prescription dose of Fentanyl had not changed since 2008 and the directions for use had not changed. There was no evidence that the application of Fentanyl patches resulting in a dose of micrograms was intentional. I found that Ms Bennett had inadvertently overdosed on Fentanyl, and that, in combination with other medicines, a number of which possessed the ability to depress the nervous system, led to her death.
Ms Benett’s GP practice was managed directly by the Health Board. It is Standard Health Board practice for medication reviews to be completed at 12-15 month intervals but, in Ms Bennett’s case, that target had not been met on a single occasion since 2015. There is a lack of monitoring and no standardised process for medication reviews in the Health Board managed practices.
There is a risk of harm if medication reviews are not undertaken at regular intervals, including a risk of death in complex cases, like Ms Bennett’s. There is also a risk of harm or death if all pertinent matters are not considered during the reviews. At inquest, the Health Board produced an improvement plan that, inter alia, included actions to address the lack of compliance with the 12-15 monthly medication reviews. The target completion date for addressing the lack of compliance with the 12-15 monthly medication reviews is the 31st May 2025, a further 15 months from now. This, in my view, is not quick enough and I am concerned that future deaths may occur.
Copies Sent To
who in my opinion should receive it
Signature_________________________ Assistant Coroner for North West Wales
Similar PFD Reports
Reports sharing organisations, categories, or themes with this PFD
Related Inquiry Recommendations
Public inquiry recommendations addressing similar themes
Transfusion Committees and Tranexamic Acid - England
Infected Blood Inquiry
High-risk medication monitoring
Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.