Kumaran Chetty
PFD Report
All Responded
Ref: 2024-0629
Alcohol, drug and medication related deaths
Community health care and emergency services related deaths
All 1 response received
· Deadline: 9 Jan 2025
Coroner's Concerns (AI summary)
The GP surgery failed to identify excessive fentanyl use reported in hospital correspondence, lacking proper triage procedures and specific policies to flag concerns about controlled drug abuse and initiate medication reviews.
View full coroner's concerns
I heard evidence during the inquest from of the practice. ’s evidence was that Mr. Chetty was being prescribed fentanyl patches through the practice for chronic pain. The evidence was that Mr. Chetty managed his own medication at home and was assessed to have capacity to do so.
His last prescription was for 10 patches as 1 x 25mg patch per 72 hours. s evidence was that this prescription should last Mr Chetty a month and was the maximum amount of this controlled drug that a patient could be prescribed at any one time.
On the 17th April 2024 Mr. Chetty was seen by his Consultant at Salford Royal Hospital. A letter sent to Brinnington Surgery by reported that Mr. Chetty had disclosed using multiple fentanyl patches in order to address his current levels of pain.
This report of excessive fentanyl use outside of the prescribed regime was not identified by the Surgery upon receipt of the letter and did not trigger a medication review for Mr Chetty.
I am concerned that the correspondence triage did not identify this excessive use of a controlled drug which is known to cause fatalities if abused.
I am further concerned that there are no specific policies or procedures within the Surgery to flag up or review concerns around fentanyl abuse. As a known recipient of this and other strong opiate medication, all correspondence received by the surgery relating to Mr. Chetty’s treatment and care had the potential to reveal important information about his ability to self-manage his medication.
His last prescription was for 10 patches as 1 x 25mg patch per 72 hours. s evidence was that this prescription should last Mr Chetty a month and was the maximum amount of this controlled drug that a patient could be prescribed at any one time.
On the 17th April 2024 Mr. Chetty was seen by his Consultant at Salford Royal Hospital. A letter sent to Brinnington Surgery by reported that Mr. Chetty had disclosed using multiple fentanyl patches in order to address his current levels of pain.
This report of excessive fentanyl use outside of the prescribed regime was not identified by the Surgery upon receipt of the letter and did not trigger a medication review for Mr Chetty.
I am concerned that the correspondence triage did not identify this excessive use of a controlled drug which is known to cause fatalities if abused.
I am further concerned that there are no specific policies or procedures within the Surgery to flag up or review concerns around fentanyl abuse. As a known recipient of this and other strong opiate medication, all correspondence received by the surgery relating to Mr. Chetty’s treatment and care had the potential to reveal important information about his ability to self-manage his medication.
Responses
Action Taken
The Brinnington Surgery has amended its process for incoming letters to check for flags indicating controlled drug prescriptions, updated its controlled drugs policy to limit prescriptions to 28 days, and introduced a second opinion from a named GP before prescribing opioids. The Practice has also undertaken an audit of patients on opioid/opiate medication to reduce dosage where possible and is restricting new opioid/opiate prescriptions. (AI summary)
The Brinnington Surgery has amended its process for incoming letters to check for flags indicating controlled drug prescriptions, updated its controlled drugs policy to limit prescriptions to 28 days, and introduced a second opinion from a named GP before prescribing opioids. The Practice has also undertaken an audit of patients on opioid/opiate medication to reduce dosage where possible and is restricting new opioid/opiate prescriptions. (AI summary)
View full response
Dear Madam Coroner
Our Client: The Partners of the Brinnington Surgery Inquest touching the death of Kumaran Thanappa Chetty Regulation 28 Report Response
We have been instructed jointly by Medical Protection, the MDDUS, and the MDU to assist the Brinnington Surgery (“the Practice”) in respect of its response to the Regulation 28 Report dated 14 November 2024. Please accept this letter as the Practice’s response. We are grateful for the extensions of time to provide this. On behalf of the Practice, we wish to offer our sincere condolences to Mr Chetty’s family.
The Practice acknowledges the concerns you have raised in the Regulation 28 Report. It is apparent that Mr Chetty was overordering medication and this was consequently overprescribed by the practice. The Practice has taken various steps to address all of these issues which are set out below.
Areas of Learning/Change
The Practice has undertaken two Significant Event Analysis meetings, one on 15 November 2024 and the other on 6 December 2024. The headings below set out the areas in which the Practice has made changes that are relevant to the inquest.
1. Incoming Correspondence Process
The Practice has amended its process in relation to incoming letters. Every letter that is received is reviewed by the administrative staff. They now check EMIS (the electronic records system) to check whether there is flag indicating if the patient is prescribed a controlled drug (CD). If a patient is prescribed a CD, then the letter is now reviewed by a GP the same day or the following working day at the latest. The duty GP or another GP working that day will review any letter relating to a patient that is taking a CD even if the content of the letter does not relate to the CD. Furthermore, the system is such that the incoming correspondence is not sent to a GP if they are on annual leave or they are not in the Practice for a few days.
PRIVATE & CONFIDENTIAL
Ms Anna Morris KC Assistant Coroner Greater Manchester South
By Email:
Clyde & Co LLP 2 New Bailey Square Stanley Street Salford M3 5GS Telephone: 0161 236 2002 Fax: 0161 832 7956 DX 14302 Salford
Our Ref:
Your Ref:
Date: 20 February 2025
Clyde & Co LLP is a limited liability partnership registered in England and Wales under number OC326539 and is authorised and regulated by the Solicitors Regulation Authority under number 460690. A list of members is available for inspection at its registered office The St Botolph Building, 138 Houndsditch, London EC3A 7AR. Clyde & Co LLP uses the word "partner" to refer to a member of the LLP, or an employee or consultant with equivalent standing and qualifications.
The Practice has created a workflow process map (enclosed) which now links to the individual protocol for each type of letter. This map shows what the incoming correspondence process is for each type of letter which now includes the requirement for a GP to review all incoming letters if a patient is prescribed a CD.
The Practice has performed an initial audit of this new process. As part of the audit, all documents received within a 24 – 48 hour window were checked. The results of the audit were that the admin staff were following the process and felt comfortable with it. The Practice intends to undertake an audit of the system every 3 – 6 months.
2. Improved learning and awareness regarding medication
Steps have been taken to address the issues raised above. This was discussed at the SEA meeting on 15 November 2024 and will be incorporated into future meetings. The importance of accurate prescribing is now included during inductions with junior doctors. Representatives from the practice pharmacy team were present at this meeting and were involved in the discussions. Prescribing will also be discussed at subsequent meetings. The GPs have undertaken training provided by EMIS in relation to repeat prescriptions. Further discussions took place on 17 January 2025. A new prescribing protocol is in development which was discussed at this meeting. This will include a specific policy on CD misuse. The Practice is also developing an alert within EMIS to ensure all prescribers adhere to the new system.
3. Partner-level review of guidance and journal articles
The partners at the Practice have reviewed the guidance and journal articles below. The learning gained from reviewing these documents was shared at a clinical meeting on 17 January 2025 referred to at heading 4.
Chronic pain (primary and secondary) in over 16s: assessment of all chronic pain and management of chronic primary pain Medicines associated with dependence or withdrawal symptoms: safe prescribing and withdrawal management for adults sign136_2019.pdf Opioids Aware | Faculty of Pain Medicine NICE guideline NG193 for chronic pain: reasons to be cheerful | British Journal of General Practice NICE chronic primary pain guidelines: what the busy GP needs to know
4. Clinical Meeting on 17 January 2025
The practice held a clinical meeting on 17 January 2025 to undertake further discussions about chronic pain management. This was attended by medical, nursing, and pharmacy staff. The NICE guidelines 2022 were presented to all attendees. GPs were reminded that they should not feel pushed into prescribing something if this is not appropriate or there are risks involved. GPs were encouraged to gain a second opinion from another GP colleague before starting a dependence- forming medication. The decision following the second opinion should be communicated to the patient via a text message. The link to the Greater Manchester Pain Management Resources Hub was recirculated following the meeting. During the meeting, GPs were reminded of advising patients about non-pharmacological management such as exercise, CBT, and acceptance and
Clyde & Co LLP is a limited liability partnership registered in England and Wales under number OC326539 and is authorised and regulated by the Solicitors Regulation Authority under number 460690. A list of members is available for inspection at its registered office The St Botolph Building, 138 Houndsditch, London EC3A 7AR. Clyde & Co LLP uses the word "partner" to refer to a member of the LLP, or an employee or consultant with equivalent standing and qualifications. commitment therapy (ACT) and of the importance of avoiding prescribing opiate medication in the first instance (excluding cancer patients and palliative patients). GPs were also reminded about the importance of social prescribing. Since the meeting, the Practice has sourced a treatment plan agreement developed by Greater Manchester Medicines Management Group. The Practice plans to use this going forwards when initiating fentanyl prescriptions (again, excluding cancer patients and palliative patients).
5. Opioid medication audit
The Practice has undertaken an audit of patients on opioid/opiate medication including morphine, oxycodone, fentanyl, and high strength opiates to see if the strength/dosage can be reduced. The audit started prior to this patient’s death and the Practice has been reviewing opiate prescribing for some time. The Practice has been able to reduce the dosage taken by a of number of patients. The Practice will continue its attempts to reduce the dose and strength of opioid/opiate medication for these patients. The Practice intends to undertake this audit on an annual basis. This will be in addition to the usual medication reviews which take place on a 6 – 12 monthly basis. The Practice is also restricting the new prescription of opioids/opiates. This is through education of GPs and the second opinion referred to above. The practice also has a Pain Management Health Coach who supports patients who choose to have their opioid/opiate medication reduced.
The GP partners are confident that as a result of the steps described above that matters will be dealt with differently in the future. There has been extensive learning and reflection undertaken within the Practice and we hope that you and Mr Chetty’s family will be reassured by the actions taken.
Our Client: The Partners of the Brinnington Surgery Inquest touching the death of Kumaran Thanappa Chetty Regulation 28 Report Response
We have been instructed jointly by Medical Protection, the MDDUS, and the MDU to assist the Brinnington Surgery (“the Practice”) in respect of its response to the Regulation 28 Report dated 14 November 2024. Please accept this letter as the Practice’s response. We are grateful for the extensions of time to provide this. On behalf of the Practice, we wish to offer our sincere condolences to Mr Chetty’s family.
The Practice acknowledges the concerns you have raised in the Regulation 28 Report. It is apparent that Mr Chetty was overordering medication and this was consequently overprescribed by the practice. The Practice has taken various steps to address all of these issues which are set out below.
Areas of Learning/Change
The Practice has undertaken two Significant Event Analysis meetings, one on 15 November 2024 and the other on 6 December 2024. The headings below set out the areas in which the Practice has made changes that are relevant to the inquest.
1. Incoming Correspondence Process
The Practice has amended its process in relation to incoming letters. Every letter that is received is reviewed by the administrative staff. They now check EMIS (the electronic records system) to check whether there is flag indicating if the patient is prescribed a controlled drug (CD). If a patient is prescribed a CD, then the letter is now reviewed by a GP the same day or the following working day at the latest. The duty GP or another GP working that day will review any letter relating to a patient that is taking a CD even if the content of the letter does not relate to the CD. Furthermore, the system is such that the incoming correspondence is not sent to a GP if they are on annual leave or they are not in the Practice for a few days.
PRIVATE & CONFIDENTIAL
Ms Anna Morris KC Assistant Coroner Greater Manchester South
By Email:
Clyde & Co LLP 2 New Bailey Square Stanley Street Salford M3 5GS Telephone: 0161 236 2002 Fax: 0161 832 7956 DX 14302 Salford
Our Ref:
Your Ref:
Date: 20 February 2025
Clyde & Co LLP is a limited liability partnership registered in England and Wales under number OC326539 and is authorised and regulated by the Solicitors Regulation Authority under number 460690. A list of members is available for inspection at its registered office The St Botolph Building, 138 Houndsditch, London EC3A 7AR. Clyde & Co LLP uses the word "partner" to refer to a member of the LLP, or an employee or consultant with equivalent standing and qualifications.
The Practice has created a workflow process map (enclosed) which now links to the individual protocol for each type of letter. This map shows what the incoming correspondence process is for each type of letter which now includes the requirement for a GP to review all incoming letters if a patient is prescribed a CD.
The Practice has performed an initial audit of this new process. As part of the audit, all documents received within a 24 – 48 hour window were checked. The results of the audit were that the admin staff were following the process and felt comfortable with it. The Practice intends to undertake an audit of the system every 3 – 6 months.
2. Improved learning and awareness regarding medication
Steps have been taken to address the issues raised above. This was discussed at the SEA meeting on 15 November 2024 and will be incorporated into future meetings. The importance of accurate prescribing is now included during inductions with junior doctors. Representatives from the practice pharmacy team were present at this meeting and were involved in the discussions. Prescribing will also be discussed at subsequent meetings. The GPs have undertaken training provided by EMIS in relation to repeat prescriptions. Further discussions took place on 17 January 2025. A new prescribing protocol is in development which was discussed at this meeting. This will include a specific policy on CD misuse. The Practice is also developing an alert within EMIS to ensure all prescribers adhere to the new system.
3. Partner-level review of guidance and journal articles
The partners at the Practice have reviewed the guidance and journal articles below. The learning gained from reviewing these documents was shared at a clinical meeting on 17 January 2025 referred to at heading 4.
Chronic pain (primary and secondary) in over 16s: assessment of all chronic pain and management of chronic primary pain Medicines associated with dependence or withdrawal symptoms: safe prescribing and withdrawal management for adults sign136_2019.pdf Opioids Aware | Faculty of Pain Medicine NICE guideline NG193 for chronic pain: reasons to be cheerful | British Journal of General Practice NICE chronic primary pain guidelines: what the busy GP needs to know
4. Clinical Meeting on 17 January 2025
The practice held a clinical meeting on 17 January 2025 to undertake further discussions about chronic pain management. This was attended by medical, nursing, and pharmacy staff. The NICE guidelines 2022 were presented to all attendees. GPs were reminded that they should not feel pushed into prescribing something if this is not appropriate or there are risks involved. GPs were encouraged to gain a second opinion from another GP colleague before starting a dependence- forming medication. The decision following the second opinion should be communicated to the patient via a text message. The link to the Greater Manchester Pain Management Resources Hub was recirculated following the meeting. During the meeting, GPs were reminded of advising patients about non-pharmacological management such as exercise, CBT, and acceptance and
Clyde & Co LLP is a limited liability partnership registered in England and Wales under number OC326539 and is authorised and regulated by the Solicitors Regulation Authority under number 460690. A list of members is available for inspection at its registered office The St Botolph Building, 138 Houndsditch, London EC3A 7AR. Clyde & Co LLP uses the word "partner" to refer to a member of the LLP, or an employee or consultant with equivalent standing and qualifications. commitment therapy (ACT) and of the importance of avoiding prescribing opiate medication in the first instance (excluding cancer patients and palliative patients). GPs were also reminded about the importance of social prescribing. Since the meeting, the Practice has sourced a treatment plan agreement developed by Greater Manchester Medicines Management Group. The Practice plans to use this going forwards when initiating fentanyl prescriptions (again, excluding cancer patients and palliative patients).
5. Opioid medication audit
The Practice has undertaken an audit of patients on opioid/opiate medication including morphine, oxycodone, fentanyl, and high strength opiates to see if the strength/dosage can be reduced. The audit started prior to this patient’s death and the Practice has been reviewing opiate prescribing for some time. The Practice has been able to reduce the dosage taken by a of number of patients. The Practice will continue its attempts to reduce the dose and strength of opioid/opiate medication for these patients. The Practice intends to undertake this audit on an annual basis. This will be in addition to the usual medication reviews which take place on a 6 – 12 monthly basis. The Practice is also restricting the new prescription of opioids/opiates. This is through education of GPs and the second opinion referred to above. The practice also has a Pain Management Health Coach who supports patients who choose to have their opioid/opiate medication reduced.
The GP partners are confident that as a result of the steps described above that matters will be dealt with differently in the future. There has been extensive learning and reflection undertaken within the Practice and we hope that you and Mr Chetty’s family will be reassured by the actions taken.
Sent To
- Brinnington Surgery
Response Status
Linked responses
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56-Day Deadline
9 Jan 2025
All responses received
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Source: Courts and Tribunals Judiciary
Report Sections
Investigation and Inquest
On the 14th August 2024, I commenced an investigation into the death of Mr. Kumaran Chetty. At the inquest into his death on the 11th November 2024 I found that he died from an acute cardiac episode, contributed to by fentanyl and morphine toxicity.
Circumstances of the Death
My findings at the inquest were as follows –
The deceased was 51 years old at the time of his death. He had a number of chronic health conditions including ischaemic heart disease and cardiomyopathy. On the 19th April 2024 an ECG indicated that his left ventricular function was less than 25% ejection. He also suffered from chronic pain as a result of long standing colorectal issues and was under the care of a consultant. He was prescribed fentanyl by his GP in the dose of 1 25mg patch per 72 hours. He was also prescribed morphine sulphate.
On the morning of the 9th May 2024, the deceased was found unresponsive in the kitchen at his home address. Paramedics attended and pronounced life to be extinct. Autopsy confirmed the presence of an acute left ventricular failure. Examination revealed the presence of 4 fentanyl patches on the upper back of the deceased, which was in excess of the amount he was prescribed. Toxicology reported the presence of fentanyl and morphine in levels associated with fatalities.
There is no evidence that the deceased intended to take his own life. It is not clear whether his application of the patches was a mistake or a response to the level of pain he was experiencing. However, I find the excessive, even if accidental use of these strong opiates would have had a consequent effect on his already failing heart and is likely to contributed to his death from acute left ventricular failure.
The deceased was 51 years old at the time of his death. He had a number of chronic health conditions including ischaemic heart disease and cardiomyopathy. On the 19th April 2024 an ECG indicated that his left ventricular function was less than 25% ejection. He also suffered from chronic pain as a result of long standing colorectal issues and was under the care of a consultant. He was prescribed fentanyl by his GP in the dose of 1 25mg patch per 72 hours. He was also prescribed morphine sulphate.
On the morning of the 9th May 2024, the deceased was found unresponsive in the kitchen at his home address. Paramedics attended and pronounced life to be extinct. Autopsy confirmed the presence of an acute left ventricular failure. Examination revealed the presence of 4 fentanyl patches on the upper back of the deceased, which was in excess of the amount he was prescribed. Toxicology reported the presence of fentanyl and morphine in levels associated with fatalities.
There is no evidence that the deceased intended to take his own life. It is not clear whether his application of the patches was a mistake or a response to the level of pain he was experiencing. However, I find the excessive, even if accidental use of these strong opiates would have had a consequent effect on his already failing heart and is likely to contributed to his death from acute left ventricular failure.
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.