Eric Gaskell
PFD Report
All Responded
Ref: 2016-0057
All 1 response received
· Deadline: 12 Apr 2016
Sent To
Response Status
Responses
1 of 1
56-Day Deadline
12 Apr 2016
All responses received
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Organisations named in PFD reports must respond within 56 days explaining what actions they are taking.
Source: Courts and Tribunals Judiciary
Coroner's Concerns
During the inquest evidence was heard that: - The Accident ad Emergency Department at the Royal Bolton Hospital carries stock of medication to treat patients who attend their department and are discharged without formal admission: certain medication however is stocked and antianginal medication is one of the medications that is not stocked by the Department; If a patient therefore requires such medication, or any other that is not stocked, a prescription must be issued by the treating Doctor in the Accident and Emergency Department ji_ In accordance with the current policy at The Royal Bolton Hospital, Doctors are only permitted to issue Hospital specific prescriptions, which can only be used at the Pharmacy at the Royal Bolton Hospital. They are not allowed, under the current policy, to issue standard prescription, known as an FP1O. They were able to issue a FP1O until years ago when the Hospital policy changed_ iii, The Pharmacy at the Royal Bolton Hospital is not 24 hour Pharmacy. Evidence was given at the Inquest that the Pharmacy is only open Monday to Friday 8am to 5.1Spm, Saturdays from 9am, but the closing time was not known, and some Sundays when there is a demand for it to be open when the hospital is buSy, such as the winter months_
iv. If patient attends the Accident and Emergency Department of the Hospital ad requires medication to be prescribed outside of the opening times of the Hospital Pharmacy, they will not have access to certain medications that are not carried by the Department; some of which could be lifesaving medication, as the Doctors are unable to issue prescription to be used outside of the Hospital Estate: They can be given Hospital specific prescription by a Doctor but would have to wait for the Hospital Pharmacy to open and collect it; So potentially patient who attends the Accident and Emergency Department at the Royal Bolton Hospital on a Saturday evening in summer months for example, would not have access to medication that they require until the Monday morning when the Pharmacy is open. V. Evidence was given that medication can prevent death and therefore it is possible that allowing access to medication 24 hours a whether that be by ensuring the Pharmacy is open 24 hours or by allowing Doctors to issue a FP1O prescription, could prevent a future death. Only few day, day, Ihave concerns with regard to the following: - Due to the current policy adopted by the Royal Bolton Hospital regarding the prescribing of medication, a future death could occur if person is not given 24 hour access to medication that they require and therefore request that a review be conducted by the Royal Bolton Hospital of their policies ad procedures in respect of the prescribing at the Hospital_ ACTION SHOULD BE TAKEN In my opinion urgent action should be taken to prevent future deaths and I believe you and your organisation have the power to take such action. YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report; namely by 12th April 2016. I, the coroner, may extend the period; Your response must contain details of action taken Or proposed to be taken, setting out the timetable for action. Otherwise you must explain why no action is proposed; COPIES and PUBLICATION I have sent copy of my report to the Chief Coroner and to the following Interested Persons: - Mr Gaskell's brother, I have also sent this report to the Bolton Clinical Commissioning Group, St Peter's House, Silverwell Street; Bolton BLI 1PP, who may find it useful or of interest Iam also under a duty to send the Chief Coroner a COpY of your response The Chief Coroner publish either or both in complete or redacted or summary form: He may send a copy of this report to any person who he believes may find it useful or of interest: You may make representations to me, the coroner, at the time of your response, about the release or the publication of your response by the Chief Coroner. Dated Signed Wllt 16th February 2016_ Rachael C Griffin may
iv. If patient attends the Accident and Emergency Department of the Hospital ad requires medication to be prescribed outside of the opening times of the Hospital Pharmacy, they will not have access to certain medications that are not carried by the Department; some of which could be lifesaving medication, as the Doctors are unable to issue prescription to be used outside of the Hospital Estate: They can be given Hospital specific prescription by a Doctor but would have to wait for the Hospital Pharmacy to open and collect it; So potentially patient who attends the Accident and Emergency Department at the Royal Bolton Hospital on a Saturday evening in summer months for example, would not have access to medication that they require until the Monday morning when the Pharmacy is open. V. Evidence was given that medication can prevent death and therefore it is possible that allowing access to medication 24 hours a whether that be by ensuring the Pharmacy is open 24 hours or by allowing Doctors to issue a FP1O prescription, could prevent a future death. Only few day, day, Ihave concerns with regard to the following: - Due to the current policy adopted by the Royal Bolton Hospital regarding the prescribing of medication, a future death could occur if person is not given 24 hour access to medication that they require and therefore request that a review be conducted by the Royal Bolton Hospital of their policies ad procedures in respect of the prescribing at the Hospital_ ACTION SHOULD BE TAKEN In my opinion urgent action should be taken to prevent future deaths and I believe you and your organisation have the power to take such action. YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report; namely by 12th April 2016. I, the coroner, may extend the period; Your response must contain details of action taken Or proposed to be taken, setting out the timetable for action. Otherwise you must explain why no action is proposed; COPIES and PUBLICATION I have sent copy of my report to the Chief Coroner and to the following Interested Persons: - Mr Gaskell's brother, I have also sent this report to the Bolton Clinical Commissioning Group, St Peter's House, Silverwell Street; Bolton BLI 1PP, who may find it useful or of interest Iam also under a duty to send the Chief Coroner a COpY of your response The Chief Coroner publish either or both in complete or redacted or summary form: He may send a copy of this report to any person who he believes may find it useful or of interest: You may make representations to me, the coroner, at the time of your response, about the release or the publication of your response by the Chief Coroner. Dated Signed Wllt 16th February 2016_ Rachael C Griffin may
Responses
Response received
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Dear Mrs Griffin Re:Eric Gaskell_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 Eric Gaskell on 3 February 2016 May take this opportunity to extend my sincere condolences to the family of Mr Gaskell for their loss. am sorry to learn that the course of establishing how Mr Gaskell came about his death you heard evidence which appeared to indicate the hospital does not have 24 hour access to medication that may be required by a patient: wish to assure you that this is not the case and on receipt of the Regulation 28, requested that the Chief Pharmacist and Medicines Safety Group review the matters detailed in your Report In relation to 24 hour access to medicines, the Trust's Medicines Policy (attached) outlines in Section 18 the process for the supply of medicines to patients at Bolton NHS Foundation Trust In Section
18.2.4.1 and Appendix 15 of the Medicines Policy, the process for supply of medicines outside of normal Pharmacy working hours is described in detail In addition there is Standard Operating Procedure (SOP) to be used in conjunction with the Policy_ The opening hours of the Pharmacy are: Days Hours of service Monday to Friday 8am to 8pm Saturday and Sunday and Bank Holidays gam to 3.45pm Christmas Day 1am to Zpm When a patient has attended the Accident and Emergency Department and presents a hospital prescription to the Pharmacy department during the above hours would be supplied with medication; Outside of these hours the Accident and Emergency Department may be able to supply an over-labelled or a pre-packed medicine. during they the
An over-labelled medicine is defined as the placing of a label onto a licensed medicinal product either onto the primary packing (for example in case of dropper bottles or creamlointment tubes) or onto the secondary packaging (for example, the box surrounding blister strip of packaged tablets) depending on the local requirements_ A pre-packed medicine is defined as taking the pack of a licensed medicinal product and opening it to pack down the enclosed doses of medicine into small units than were originally supplied by the manufacturer. The medicine is then repackaged and labelled with directions for use by the patient wards and departments hold stocks of over-labelled or pre-packed medicines, according to their requirements_ The Accident and Emergency Department stock 45 products that range from antibiotics to analgesia. also have an additional stock of over-labelled and pre- packed medicines for Paediatrics and for Ophthalmology: The Accident and Emergency (A&E) Department stock 1 x100 Glyceryl Trinitrate Tablets, which is used as a first line treatment of angina These are labelled as an over-labelled pack with the appropriate instructions_ Although A&E do not stock any over-labelled or pre-packed beta- blockers or calcium channel blockers, which are also first line treatments for angina, are able to supply a beta blocker from their main stock As these treatments are often administered once daily, it would be possible to provide a dose to the patient while in the department and provide a prescription for dispensing by the hospital Pharmacy the following If the required medicine was not available over-labelled or as a pre-pack then the Accident and Emergency Department have access to an Emergency Drug Cupboard: When a required medicine is not available from the Emergency Drug Cupboard and the clinician believes treatment must commence without any the clinician can contact the on-call Pharmacist as outlined in Appendix 15 of the Medicines Policy: The on-call Pharmacist can be contacted via the hospital switchboard and asked to come in to dispense the prescription. The decision to cease using Generic prescription forms (FP1Os) in A&E was based on number of factors. Bolton NHS Foundation is unable monitor the adherence to agreed formulary choices for medicines nor is it able to guarantee that suitable clinical checks made by Pharmacist prior to supply has been completed: This has the potential to cause harm to patients and incurs additional costs to Bolton NHS Foundation Trust that would otherwise be resolved at source. There is also the additional cost of supplying medicines using FP1Os as these prescriptions attract dispensing fee provided to the community Pharmacy and the likelihood that the cost of the drugs is not able to be matched by the hospital contract pricing structure The above outlines the measures in place that the Medicines Safety Group believes mitigate the matters of concern highlighted in your report, however addition the Medicines Safety Group have agreed the following actions and timescales: Action Target Date To be actioned by Review the existing stock list of over-labelled 31 May 2016 Steve Simpson, Chief and pre-packed medicines with Accident and Pharmacist Emergency Department Advertise the opening hours and the process April 2016 Steve Simpson, Chief for obtaining medicines out of hours with Pharmacist Accident and Emergency Department Memorandum to all Wards and Departments Completed 25 Steve Simpson regarding the supply of medicines out of February 2016 hours_ am confident that the Trust has the necessary systems in place to ensure medication is available for patients regardless of the time of their attendance. the Many They they day: delay;
Cont'd. 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 assistance please do not hesitate to contact me_
18.2.4.1 and Appendix 15 of the Medicines Policy, the process for supply of medicines outside of normal Pharmacy working hours is described in detail In addition there is Standard Operating Procedure (SOP) to be used in conjunction with the Policy_ The opening hours of the Pharmacy are: Days Hours of service Monday to Friday 8am to 8pm Saturday and Sunday and Bank Holidays gam to 3.45pm Christmas Day 1am to Zpm When a patient has attended the Accident and Emergency Department and presents a hospital prescription to the Pharmacy department during the above hours would be supplied with medication; Outside of these hours the Accident and Emergency Department may be able to supply an over-labelled or a pre-packed medicine. during they the
An over-labelled medicine is defined as the placing of a label onto a licensed medicinal product either onto the primary packing (for example in case of dropper bottles or creamlointment tubes) or onto the secondary packaging (for example, the box surrounding blister strip of packaged tablets) depending on the local requirements_ A pre-packed medicine is defined as taking the pack of a licensed medicinal product and opening it to pack down the enclosed doses of medicine into small units than were originally supplied by the manufacturer. The medicine is then repackaged and labelled with directions for use by the patient wards and departments hold stocks of over-labelled or pre-packed medicines, according to their requirements_ The Accident and Emergency Department stock 45 products that range from antibiotics to analgesia. also have an additional stock of over-labelled and pre- packed medicines for Paediatrics and for Ophthalmology: The Accident and Emergency (A&E) Department stock 1 x100 Glyceryl Trinitrate Tablets, which is used as a first line treatment of angina These are labelled as an over-labelled pack with the appropriate instructions_ Although A&E do not stock any over-labelled or pre-packed beta- blockers or calcium channel blockers, which are also first line treatments for angina, are able to supply a beta blocker from their main stock As these treatments are often administered once daily, it would be possible to provide a dose to the patient while in the department and provide a prescription for dispensing by the hospital Pharmacy the following If the required medicine was not available over-labelled or as a pre-pack then the Accident and Emergency Department have access to an Emergency Drug Cupboard: When a required medicine is not available from the Emergency Drug Cupboard and the clinician believes treatment must commence without any the clinician can contact the on-call Pharmacist as outlined in Appendix 15 of the Medicines Policy: The on-call Pharmacist can be contacted via the hospital switchboard and asked to come in to dispense the prescription. The decision to cease using Generic prescription forms (FP1Os) in A&E was based on number of factors. Bolton NHS Foundation is unable monitor the adherence to agreed formulary choices for medicines nor is it able to guarantee that suitable clinical checks made by Pharmacist prior to supply has been completed: This has the potential to cause harm to patients and incurs additional costs to Bolton NHS Foundation Trust that would otherwise be resolved at source. There is also the additional cost of supplying medicines using FP1Os as these prescriptions attract dispensing fee provided to the community Pharmacy and the likelihood that the cost of the drugs is not able to be matched by the hospital contract pricing structure The above outlines the measures in place that the Medicines Safety Group believes mitigate the matters of concern highlighted in your report, however addition the Medicines Safety Group have agreed the following actions and timescales: Action Target Date To be actioned by Review the existing stock list of over-labelled 31 May 2016 Steve Simpson, Chief and pre-packed medicines with Accident and Pharmacist Emergency Department Advertise the opening hours and the process April 2016 Steve Simpson, Chief for obtaining medicines out of hours with Pharmacist Accident and Emergency Department Memorandum to all Wards and Departments Completed 25 Steve Simpson regarding the supply of medicines out of February 2016 hours_ am confident that the Trust has the necessary systems in place to ensure medication is available for patients regardless of the time of their attendance. the Many They they day: delay;
Cont'd. 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 assistance please do not hesitate to contact me_
Report Sections
Investigation and Inquest
On the 10th November 2015 I commenced an investigation into the death of Eric Albert Gaskell; born on the 24t October 1966. The investigation concluded at the end of the Inquest on the 3rd February 2016. The Medical Cause of Death was:- la Ischaemic Heart Disease b Coronary Artery Thrombus 1c Coronary Artery Atheroma The conclusion of the inquest was Natural Causes: CIRCUMSTANCES OF THE DEATH On the 6th November 2015 Mr Gaskell attended at the Royal Bolton Hospital, Bolton complaining of chest Following assessment, which included an ECG and blood tests with normal results, he was discharged later that day from the Accident and Emergency Department with presumed diagnosis of stable angina. Upon discharge he was advised to contact his General Practitioner over the course of the next few days: On the &th November 2015, during his work as a recovery vehicle driver on the M6O motorway, Mr Gaskell collapsed: He was taken to the Salford Royal Hospital_Salford where he died; pain.
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.