Hayley Sheehan
PFD Report
All Responded
Ref: 2017-0324
All 1 response received
· Deadline: 28 Jan 2018
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56-Day Deadline
28 Jan 2018
All responses received
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Source: Courts and Tribunals Judiciary
Coroner's Concerns
The procedure for issuing repeat prescriplions relies heavily up-on the prescription administrators identifying and flagging early requests to GPs As far as was aware, the software used by the surgery does not automatically identify early prescription requests Consideration should be given to introducing more safeguards to en-sure that early requests for repeat prescriptions are identified and drawn to the attention of a GP. This should include giving considera-tion to whelher the relevant software can be adapted to automatically identify early prescription requests.
Responses
Response received
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Dear Crawford, Re: Mrs Hayley Denise SHEEHAN (Deceased) Regulation 28 Report to Prevent Future Deaths Further to your letter dated 1st August regarding Regulation 28 Report to Prevent Future Deaths and that 'consideration should be given to introducing more safeguards to ensure that early requests for repeat prescriptions are identified and drawn to the attention of a GP. This should include giving consideration to whether the relevant software can be adapted to automatically identify early prescription requests. A meeting was held at the Moat House Surgery attended by the GP Partners, Practice Manager, IT Manager and the lead clinical administrator on 17th August 2017. Following discussion at the meeting an e-mail was sent to EMIS Health, the provider of our clinical software system EMIS Web, requesting changes to the EMIS prescribing process, so that early prescription requests are 'flagged up' enclose copies of the correspondence_ In the meantime, our IT Manager has developed a pop-up box within patients' notes which alerts the issuer of a prescription to the fact that a previous prescription had been issued less than 30 previously. The pop-up box can be configured to an early request for all drugs, a particular or drug ingredient: It is currently configured to use a predefined list of products with controlled drug ingredients The 'safety net' feature added to the EMIS Web system is a template called 'Controlled Monitoring' , which will include all patients who are on Tramadol and opioid-based medication and will be grouped according to their registered GP, A search will be carried out on the 1st Monday of every month and the GPs concerned will be advised to carry out a medication Welsltzo: www? themoalhhousosurgery.co. Email; support@themoathousesurgery co.uk Ms days flag drug; Drug
review; The search will list all opioid products and Tramadol Hydrochloride products issued in the last month where a medication review was not performed in the last three months GP'$ can use the template to find out how many medications been issued to a particular patient and will set a date for the next medication review, The Clinical Administrators can see the pop-up warning and will also be able to see the last medication review date in the Medication screen and will be able tox Decline the request Bring to the attention of the relevant GP that medications are being requested too early Bring to the attention ofthe relevant GP if there are concerns that patients may be stockpiling medication or using them in excess of the prescribed dose. We are addressing the concerns raised by You, thereby providing improved safeguarding for our patients against any further serious incidents resulting from accidental overdose of medication_
review; The search will list all opioid products and Tramadol Hydrochloride products issued in the last month where a medication review was not performed in the last three months GP'$ can use the template to find out how many medications been issued to a particular patient and will set a date for the next medication review, The Clinical Administrators can see the pop-up warning and will also be able to see the last medication review date in the Medication screen and will be able tox Decline the request Bring to the attention of the relevant GP that medications are being requested too early Bring to the attention ofthe relevant GP if there are concerns that patients may be stockpiling medication or using them in excess of the prescribed dose. We are addressing the concerns raised by You, thereby providing improved safeguarding for our patients against any further serious incidents resulting from accidental overdose of medication_
Action Should Be Taken
In my opinion action should be taken to prevent futture deaths and I be-lieve that the people listed in paragraph one above have the power to take such action.
Report Sections
Investigation and Inquest
An investigation was commenced on 28 Novernber 2016 and the inquest into the death of Hayley Denise Sheehan was opened on 9 January 2017 . It was resumed and concluded on 26 July 2017. The mnedical cause of death was found to have been: la, Tramadol The inquest concluded with a short form conclusion of ' Accident
Circumstances of the Death
Mrs Sheehan suffered from fibromyalgia. She was a patient at the Moat House Surgery in Merstham, where she received a repeat prescription for 112 slow release Tramadol tablets every two months, to be taken twice a day. Surrey toxicity-200n1g
On 22 November 2016 Mrs Sheehan collapsed and dlied at her home dress, having unintentionally overdosed on her prescription Tramadol. The medical cause of her death was found to be la. Tramadol toxicity. the Forensic Toxicologist; gave evidence that the levels of Tramadol present in Mrs Sheehan's systern were consistent either with her having taken 25 tablets shortly before her death 01, alternatively, with her having taken her prescribed dose more than twice a over a more prolonged period of time: a GP partner at the Moat House Surgery, told the court that the period from 9 February to 7 November 2016 Mrs Sheehan had regularly requested her repeat prescription for Tramadol early and a8 a result she was able to obtain a total of 896 tablets as opposed to the 560 tablets which were envisaged by her repeat prescription, an excess of 336 tablets With regards to the last prescription before her death Mrs Sheehan received a prescription of 112 tablets on 7 November 2016, despite her next prescription not being due until the beginning of De-cember 2016 told the court that patients' requests for repeat prescriptions are dealt with by prescription administrators who receive the request and then prepare the prescription for a GP to sign, The system in place is such that in the event that & patient requests & prescription too early, the administrator should draw the request to the attention ofa GP, who then makes a decision with regards to whether or not to authorise it: Having congidered the evidence, the court found that Mrs Sheehan' $ requests for early prescriptions had not been identified, 0 acted upon during the course of 2016, and that as a result she had been able to ob-tain a significant amount of excess medication: told the court that following Mrs Sheehan's death the prescrip-tion administrators have been trained to highlight early requests for re-peat prescriptions to GPs_ He also said that new procedures have been introduced in respect of the prescription of Tramadol, and thatin par-ticular the Surgery now only prescribes itas an acute prescription, as opposed to a repeat prescription: told the court that the Sur-gery was considering introducing similr measures in respect of other controlled medicines_ ad-day = during
On 22 November 2016 Mrs Sheehan collapsed and dlied at her home dress, having unintentionally overdosed on her prescription Tramadol. The medical cause of her death was found to be la. Tramadol toxicity. the Forensic Toxicologist; gave evidence that the levels of Tramadol present in Mrs Sheehan's systern were consistent either with her having taken 25 tablets shortly before her death 01, alternatively, with her having taken her prescribed dose more than twice a over a more prolonged period of time: a GP partner at the Moat House Surgery, told the court that the period from 9 February to 7 November 2016 Mrs Sheehan had regularly requested her repeat prescription for Tramadol early and a8 a result she was able to obtain a total of 896 tablets as opposed to the 560 tablets which were envisaged by her repeat prescription, an excess of 336 tablets With regards to the last prescription before her death Mrs Sheehan received a prescription of 112 tablets on 7 November 2016, despite her next prescription not being due until the beginning of De-cember 2016 told the court that patients' requests for repeat prescriptions are dealt with by prescription administrators who receive the request and then prepare the prescription for a GP to sign, The system in place is such that in the event that & patient requests & prescription too early, the administrator should draw the request to the attention ofa GP, who then makes a decision with regards to whether or not to authorise it: Having congidered the evidence, the court found that Mrs Sheehan' $ requests for early prescriptions had not been identified, 0 acted upon during the course of 2016, and that as a result she had been able to ob-tain a significant amount of excess medication: told the court that following Mrs Sheehan's death the prescrip-tion administrators have been trained to highlight early requests for re-peat prescriptions to GPs_ He also said that new procedures have been introduced in respect of the prescription of Tramadol, and thatin par-ticular the Surgery now only prescribes itas an acute prescription, as opposed to a repeat prescription: told the court that the Sur-gery was considering introducing similr measures in respect of other controlled medicines_ ad-day = during
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.