Raymond Watkins
PFD Report
All Responded
Ref: 2024-0353
All 1 response received
· Deadline: 21 Aug 2024
Coroner's Concerns (AI summary)
District nurses lack clear guidance and proper authorisations for administering time-critical medicines in community settings, risking delayed or incorrect treatment.
View full coroner's concerns
1. During the course of the evidence the court heard that receipt of correct authorisations in respect of medicines is an issue faced by District Nurses in many areas of the country. Currently there is no 'Time Critical Medicine" guidance for the community setting.
Responses
Action Planned
The Department of Health and Social Care notes that NHS England is developing a Time Critical Medicines Safety Improvement Programme to identify opportunities for improvement and make recommendations on how to prevent harm to patients and that each ICB with non-medical prescribing (NMP) lead should review their current and potential NMP workforce for their conurbation of district nursing services as a priority, which will mitigate against medication delay and any patient harm. (AI summary)
The Department of Health and Social Care notes that NHS England is developing a Time Critical Medicines Safety Improvement Programme to identify opportunities for improvement and make recommendations on how to prevent harm to patients and that each ICB with non-medical prescribing (NMP) lead should review their current and potential NMP workforce for their conurbation of district nursing services as a priority, which will mitigate against medication delay and any patient harm. (AI summary)
View full response
Dear Joanne,
Thank you for the Regulation 28 report of 26 June 2024 sent to the Department of Health and Social Care about the death of Raymond Horace Watkins. I am replying as the Minister with responsibility for prescribing.
Firstly, I would like to say how saddened I was to read of the circumstances of Mr Watkins’ death, and I offer my sincere condolences to their family and loved ones. The circumstances your report describes are concerning and I am grateful to you for bringing these matters to my attention.
The report noted particular concerns as follows:
• During the course of the evidence the court heard that receipt of correct authorisations in respect of medicines is an issue faced by District Nurses in many areas of the country. Currently there is no “Time Critical Medicine” guidance for the community setting.
In preparing this response, Departmental officials have made enquiries with NHS England as the organisation with responsibility in this area.
NHS England has advised that all clinicians involved in processing medication should know how to access national and local prescribing guidance. The administration of medicines in a health care setting must be done in accordance with a prescription, Patient Specific Direction, Patient Group Direction or other relevant exemption specified in the Human Medicines Regulations 2012. Professional Guidance on the Administration of Medicines in Healthcare Settings (January 2019) covers the administration of medicines, verbal orders, transcribing and covert administration. This professional guidance has been
From
Minister of State for Health
39 Victoria Street London SW1H 0EU
co-produced by the Royal Pharmaceutical Society and the Royal College of Nursing and provides principles-based guidance to ensure the safe administration.
NHS England has advised that in reviewing the report, it appears that there were failings on both sides, (i.e. the GP practice and the district nurse service), with what appears to be a breakdown in communication and other human factors at play. Therefore, any response to address the issues will require a collective multidisciplinary approach across provider and community organisations.
This case does highlight the importance of strengthening prescribing partnerships in every community setting between district nurses (who are not independent prescribers) GP practices and care homes. Each ICB with non-medical prescribing (NMP) lead should review their current and potential NMP workforce for their conurbation of district nursing services as a priority, which will mitigate against medication delay and any patient harm.
NHS England further advises that insulin is a recognised time critical medication that district nursing services aim to prioritise and patients receiving straight forward insulin prescriptions are often given their insulin by healthcare support workers who have been delegated this responsibility by the registered nurse overseeing the patient’s care. (Time sensitive medicines - Care Quality Commission (cqc.org.uk). District nursing services do not cap patient referrals and it is assumed that in this case the patient will have been referred to the service and prioritised.
Finally, NHS England is in the process of developing a Time Critical Medicines Safety Improvement Programme in partnership with Parkinson’s UK, Epilepsy Society, and other key stakeholders. Over the three years, the programme is set to identify opportunities for improvement and make recommendations on how to prevent harm to patients.
I hope this response is helpful. Thank you for bringing these concerns to my attention.
Thank you for the Regulation 28 report of 26 June 2024 sent to the Department of Health and Social Care about the death of Raymond Horace Watkins. I am replying as the Minister with responsibility for prescribing.
Firstly, I would like to say how saddened I was to read of the circumstances of Mr Watkins’ death, and I offer my sincere condolences to their family and loved ones. The circumstances your report describes are concerning and I am grateful to you for bringing these matters to my attention.
The report noted particular concerns as follows:
• During the course of the evidence the court heard that receipt of correct authorisations in respect of medicines is an issue faced by District Nurses in many areas of the country. Currently there is no “Time Critical Medicine” guidance for the community setting.
In preparing this response, Departmental officials have made enquiries with NHS England as the organisation with responsibility in this area.
NHS England has advised that all clinicians involved in processing medication should know how to access national and local prescribing guidance. The administration of medicines in a health care setting must be done in accordance with a prescription, Patient Specific Direction, Patient Group Direction or other relevant exemption specified in the Human Medicines Regulations 2012. Professional Guidance on the Administration of Medicines in Healthcare Settings (January 2019) covers the administration of medicines, verbal orders, transcribing and covert administration. This professional guidance has been
From
Minister of State for Health
39 Victoria Street London SW1H 0EU
co-produced by the Royal Pharmaceutical Society and the Royal College of Nursing and provides principles-based guidance to ensure the safe administration.
NHS England has advised that in reviewing the report, it appears that there were failings on both sides, (i.e. the GP practice and the district nurse service), with what appears to be a breakdown in communication and other human factors at play. Therefore, any response to address the issues will require a collective multidisciplinary approach across provider and community organisations.
This case does highlight the importance of strengthening prescribing partnerships in every community setting between district nurses (who are not independent prescribers) GP practices and care homes. Each ICB with non-medical prescribing (NMP) lead should review their current and potential NMP workforce for their conurbation of district nursing services as a priority, which will mitigate against medication delay and any patient harm.
NHS England further advises that insulin is a recognised time critical medication that district nursing services aim to prioritise and patients receiving straight forward insulin prescriptions are often given their insulin by healthcare support workers who have been delegated this responsibility by the registered nurse overseeing the patient’s care. (Time sensitive medicines - Care Quality Commission (cqc.org.uk). District nursing services do not cap patient referrals and it is assumed that in this case the patient will have been referred to the service and prioritised.
Finally, NHS England is in the process of developing a Time Critical Medicines Safety Improvement Programme in partnership with Parkinson’s UK, Epilepsy Society, and other key stakeholders. Over the three years, the programme is set to identify opportunities for improvement and make recommendations on how to prevent harm to patients.
I hope this response is helpful. Thank you for bringing these concerns to my attention.
Sent To
- Department of Health and Social Care
Response Status
Linked responses
1 of 1
56-Day Deadline
21 Aug 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
Report Sections
Investigation and Inquest
On the 21 st December 2022, I commenced an investigation into the death of Raymond Horace Watkins. Raymond Watkins died on the 28th November 2022 at Royal Oldham hospital. The investigation concluded on the 26th June 2024. The medical cause of death was confirmed as 1a) Septicaemia 1b) Insulin controlled Type 2 Diabetes, Chronic Obstructive Pulmonary Disease, lschaemic Heart Disease, Pressure Ulcers 2) Cerebrovascular Accident
Circumstances of the Death
Mr Watkins had been admitted to hospital on the 4th November 2022. During this admission he was placed on end of life palliative care and his usual medications including his insulin were stopped. He was discharged from hospital on the 10th November 2022 to his care home. The following day Mr Watkins advised the home, his GP and others that he wanted to restart his medications including his insulin. At this stage Mr Watkins had capacity and his clinical picture had improved. The GP prescribed his insulin and the authorisation required by the District Nurses for them to administer the same. The court heard that an authorisation is required before District Nurses can administer the same. Due to administrative errors both within the GP practice and the District Nurse practice this prescription was not authorised before Mr Watkins was readmitted to hospital on the 22nd November 2022. An initial forensic post mortem had considered the medical cause of death to be directly attributable to the lack of insulin however further expert evidence concluded that the prescribing of further insulin would, in this case not have been appropriate and in any event would not have made any difference. The cause of death was therefore revised. However it was acknowledged by all Interested Persons and the expert that the breakdown in communication between the GP and District Nurses was indefensible and could in a different case have been causative. As a result of their investigation into this case the Northern Care Alliance has developed and rolled out across 4 areas of Greater Manchester a "Time Critical Medicine" process for District Nurses advising them as to which medicines are considered time critical and what steps to take if authorisations are not correctly completed on receipt. This includes: ContactinQ the Prescriber and immediately raisinQ a datix incident 8
- Returning to the prescriber within 2 hours if correct authorisation is not received
- Escalation by end of shift to a manager
- Escalation following morning to the Assistant Director of Nursing The implementation of this Standard Operating Procedure which came into place in March 2024, led to the number of datix incidents increasing significantly, highlighting the widespread issue. However since its implementation this has raised the awareness amongst GPs and prescribers of errors and the numbers have declined dramatically to the point where practices are making real differences to the ability for patients to access such medicines.
- Returning to the prescriber within 2 hours if correct authorisation is not received
- Escalation by end of shift to a manager
- Escalation following morning to the Assistant Director of Nursing The implementation of this Standard Operating Procedure which came into place in March 2024, led to the number of datix incidents increasing significantly, highlighting the widespread issue. However since its implementation this has raised the awareness amongst GPs and prescribers of errors and the numbers have declined dramatically to the point where practices are making real differences to the ability for patients to access such medicines.
Copies Sent To
Northern Care Alliance
Abbeycare Care Home
Alexandra Group Medical Practice
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.