Penelope Benton
PFD Report
All Responded
Ref: 2017-0349
All 1 response received
· Deadline: 29 Jan 2018
Response Status
Responses
1 of 1
56-Day Deadline
29 Jan 2018
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. Evidence emerged during the inquest that the General Practitioner wasn’t made aware of the previous tramadol overdose on the discharge letter from Hospital.
Responses
Response received
View full response
Dear Mr Siddique
Ref: Penelope Benton Regulation 28 Ruling – Dudley and Walsall Mental Health Partnership NHS Trust Response
I am writing on behalf of Dudley and Walsall Mental Health Partnership NHS Trust in response to the recent HM Coroners Regulation 28 Report issued to the Trust, following the recent coronial inquest into the death of Ms Penelope Benton.
I would, first of all, like to pass on our sincere condolences and state that the Trust is fully committed to providing excellent Mental Health care to the service users of Dudley and Walsall in a way which is safe and effective for patients and their families.
The Trust acknowledges the fact that in this instance the General Practitioner was not made aware of the previous tramadol overdose in the discharge letter from hospital. The Trust has agreed standards in relation to ensuring good communication with General Practitioners which includes the standards expected when writing discharge letters. A copy of these standards can be found within appendix 2 of this response. Unfortunately in this instance, whilst the discharge letter addressed all the key areas outlined within the standard/template, the information contained within the letter was inaccurate in this single point and failed to include details of this overdose.
As a Trust which constantly looks to improve its services and learn lessons from incidents, the Trust will conduct a review of its standards around discharge communications and reiterate the importance to medical staff that incidents and risk factors are included within discharge letters where this is necessary.
It should also be noted that consultant teams also undertake audits in relation to the quality of discharge letters and communication with GPs to ensure / monitor the quality of discharge communication and ensure that the standard of these letters remains high. A required frequency / standard of audit and checking will be agreed as part of this review
and will be communicated to medical teams. A summary of these proposed actions is outlined within the enclosed appendix 1.
I trust that the proposed course of action addresses the areas of concern outlined within your regulation 28 report to the Trust however should you have any further concerns please do not hesitate to contact us for more information.
Ref: Penelope Benton Regulation 28 Ruling – Dudley and Walsall Mental Health Partnership NHS Trust Response
I am writing on behalf of Dudley and Walsall Mental Health Partnership NHS Trust in response to the recent HM Coroners Regulation 28 Report issued to the Trust, following the recent coronial inquest into the death of Ms Penelope Benton.
I would, first of all, like to pass on our sincere condolences and state that the Trust is fully committed to providing excellent Mental Health care to the service users of Dudley and Walsall in a way which is safe and effective for patients and their families.
The Trust acknowledges the fact that in this instance the General Practitioner was not made aware of the previous tramadol overdose in the discharge letter from hospital. The Trust has agreed standards in relation to ensuring good communication with General Practitioners which includes the standards expected when writing discharge letters. A copy of these standards can be found within appendix 2 of this response. Unfortunately in this instance, whilst the discharge letter addressed all the key areas outlined within the standard/template, the information contained within the letter was inaccurate in this single point and failed to include details of this overdose.
As a Trust which constantly looks to improve its services and learn lessons from incidents, the Trust will conduct a review of its standards around discharge communications and reiterate the importance to medical staff that incidents and risk factors are included within discharge letters where this is necessary.
It should also be noted that consultant teams also undertake audits in relation to the quality of discharge letters and communication with GPs to ensure / monitor the quality of discharge communication and ensure that the standard of these letters remains high. A required frequency / standard of audit and checking will be agreed as part of this review
and will be communicated to medical teams. A summary of these proposed actions is outlined within the enclosed appendix 1.
I trust that the proposed course of action addresses the areas of concern outlined within your regulation 28 report to the Trust however should you have any further concerns please do not hesitate to contact us for more information.
Action Should Be Taken
1. You may wish to consider urgently reviewing the discharge process and information shared with primary health services on discharge of patients.
Report Sections
Investigation and Inquest
On the 20 September 2017, I commenced an investigation into the death of the late Ms Penelope Benton. The investigation concluded at the end of the inquest on 31 October 2017. The conclusion of the inquest was a short narrative conclusion of suicide.
The cause of death was:
1a Tramadol Overdose
The cause of death was:
1a Tramadol Overdose
Circumstances of the Death
i) Ms Benton had a complex medical history including diagnosed paranoid schizophrenia and also a history of self-harm including drugs overdoses. She also had a stoma fitted following an obstruction to her bowel. This had caused significant pain over a number of years. ii) On the 22 September 2016 she was admitted to Bushey Field Hospital after a relapse and sectioned under S3 Mental Health Act. She disclosed to her care co-coordinator on the 26 September 2016 that she had taken an overdose of 60 Tramadol tablets and that she had had enough of her pain and wanted it to go away. iii) After making improvement she was discharged with support in the community on the 18 October 2016. The discharge note did not record any details of the Tramadol overdose and the GP continued to give her Tramadol medication for pain relief. iv) On the 12 July 2017, Ms Benton took a significant quantity of Tramadol tablets (40.4mg/L) and fatalities have been associated with concentrations of greater than 6 mg/L. v) Sadly, she was pronounced deceased on the same day and the cause of death was later confirmed as Tramadol overdose.
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.