Juanita Nti
PFD Report
All Responded
Ref: 2023-0301
All 1 response received
· Deadline: 1 Nov 2023
Coroner's Concerns (AI summary)
Unclear morphine prescription details and an EMIS system lacking correct drug strengths led to a GP and pharmacist dispensing an incorrect, higher dose, resulting in a child's fatal overdose.
View full coroner's concerns
The hospital originally prescribed 120 micrograms of morphine sulphate 6 hourly and dispensed 100 micrograms per ml solution, but the strength and volume to be administered were not clearly recorded on the plan sent to the GP. The mother requested her GP by telephone to continue the prescription. The GP found only one strength of morphine on the EMIS prescription system, 10mg/5mls, confirmed to be the lowest strength available in the British National Formulary. He wrote this in the first line of the prescription and then confusingly further added “100 micrograms per ml solution, 120 micrograms 6hrly”.
The pharmacist did not notice that the second line contained a different concentration and dispensed the higher dose without stipulating the volume to be administered. The baby received 3mg instead of the intended 150 micrograms.
Whilst both GP and pharmacist made errors in clinical practice and did not contact each other, the error would not have occurred had another strength of morphine been a choice on EMIS. EMIS have been notified and placed the special prescription on its drug data base. The local commissioning group is conducting a project to identify other special prescriptions that are not on EMIS that may pose a similar risk to safety.
6.
THE REPORT IS BEING SENT TO:
Chief Executive of NHS England, Skipton House, London, SE1 6LH
The pharmacist did not notice that the second line contained a different concentration and dispensed the higher dose without stipulating the volume to be administered. The baby received 3mg instead of the intended 150 micrograms.
Whilst both GP and pharmacist made errors in clinical practice and did not contact each other, the error would not have occurred had another strength of morphine been a choice on EMIS. EMIS have been notified and placed the special prescription on its drug data base. The local commissioning group is conducting a project to identify other special prescriptions that are not on EMIS that may pose a similar risk to safety.
6.
THE REPORT IS BEING SENT TO:
Chief Executive of NHS England, Skipton House, London, SE1 6LH
Responses
Action Planned
NHS England is undertaking national work by paediatric experts to reduce the likelihood of incorrect oral morphine preparations being prescribed, including a specials formulary, standardisation of strengths of paediatric oral liquids, national guidelines, and a national approach to GP prescribing systems. The London region Controlled Drugs Accountable Officer will discuss this issue with all London ICB medications safety representatives and ensure regional oversight of implementation of action plans. (AI summary)
NHS England is undertaking national work by paediatric experts to reduce the likelihood of incorrect oral morphine preparations being prescribed, including a specials formulary, standardisation of strengths of paediatric oral liquids, national guidelines, and a national approach to GP prescribing systems. The London region Controlled Drugs Accountable Officer will discuss this issue with all London ICB medications safety representatives and ensure regional oversight of implementation of action plans. (AI summary)
View full response
Dear Coroner,
Re: Regulation 28 Report to Prevent Future Deaths – Juanita Boate Nti who died on 9 September 2020.
Thank you for your Report to Prevent Future Deaths (hereafter “Report”) dated Friday 18 August 2023 concerning the death of Juanita Boate Nti on 9 September 2020. In advance of responding to the specific concerns raised in your Report, I would like to express my deep condolences to Juanita’s parents and family. NHS England are keen to assure the family and the coroner that the concerns raised about Juanita’s care have been listened to and reflected upon.
Your Report raises the concern that clinical practice errors were made regarding the prescription of and dispensing of oral morphine preparation to be administered to Juanita. Further, that the error would not have occurred had the lower strength of morphine been a choice on the EMIS prescription service and that the whole of the NHS should ensure local health economy wide paediatric prescribing policies.
NHS England is aware that in the last three years, there have unfortunately been three serious incidents where an incorrect oral morphine preparation was prescribed and dispensed to a baby. We are aware that issues have included a lack of awareness and clarity over a medicine being a special preparation as well as poor communication between medical professionals and with the parents of the child.
National work is underway by paediatric experts to consider what needs to be done to reduce the likelihood of a recurrence. This work incorporates several related workstreams including a specials formulary, with standardisation of strengths of paediatric oral liquids, recognition in NHS payment schemes, national guidelines, standardisation of RAG lists1 and a national approach and input into GP Prescribing systems, including using the NHS dictionary of medicines and devices (dm+d) codes for special prescriptions. The dm+d is a dictionary of descriptions and codes which represent medicines and devices in use across the NHS. It must be used when electronic systems exchange or share information about medicines relating directly to a patient’s care. I note from your Report that EMIS have already placed the special prescription on its drug data base.
1 RAG stands for red, amber, green and the RAG List provides professional guidance for practitioners in both primary and secondary care as to where responsibility should sit for prescribing. National Medical Director NHS England Wellington House 133-155 Waterloo Road London SE1 8UG
13 November 2023
The national Patient Safety Team at NHS England are aware of the issues and the Royal College of Paediatrics and Child Health (RCPCH) and the Neonatal and Paediatric Pharmacy Group (NPPG) Joint Medicines Committee is currently undertaking a ‘Review of the Management of the Supply of Unlicensed Liquid Medicines to Children’, which includes the workstreams referenced above. NHS England awaits a statement from the Group as to next steps later in November 2023, and further actions and discussions will then then take place. We can update the Coroner once we have an update. NHS England also understands that the Advisory Council on the Misuse of Drugs’ Technical Committee is reviewing the safety of liquid morphine and will carefully consider outcomes and recommendations arising from this. There is also national guidance from the National Institute for Health and Care Excellence (NICE) on End of life care for infants, children and young people with life- limiting conditions and guidance on the use of morphine in palliative care and young children: Morphine | Drugs | BNF | NICE At a more regional level, a Patient Safety Learning Bulletin was circulated across South East London by South East London Clinical Commissioning Group (since replaced by South East London Integrated Care Board (ICB)) following this incident. This included key learning points relating to prescribing and dispensing of unlicensed specials. A ‘Specials Team’ has also been established which works across the whole health system and has incorporated work relating to the outcomes of the Serious Incident Report that reviewed the circumstances of Juanita’s death. Broader work on the EMIS formulary is also progressing with the ICB’s Children and Young People’s Formulary Team to rationalise the number of oral liquid options from which products can be chosen. Other London systems have also undertaken work in this area, for example North East London have undertaken local work to align their internal formulary against the national list of recommended strength specials in 2019, and updated these again in 2021: Standardised strengths of liquid medicines for children – NPPG.
The London region Controlled Drugs Accountable Officer will also be discussing this issue with all London ICB medications safety representatives and ensure regional oversight of implementation of action plans which will include communications to GPs and community pharmacists.
NHS England is also aware that of work being undertaken in other regions, including the North East, on this issue.
I would also like to provide further assurances on national NHS England work taking place around the Reports to Prevent Future Deaths. All reports received are discussed by the Regulation 28 Working Group, comprising Regional Medical Directors, and other clinical and quality colleagues from across the regions. This ensures that key learnings and insights around preventable deaths are shared across the NHS at both a national and regional level and helps us pay close attention to any emerging trends that may require further review and action.
Thank you for bringing these important patient safety issues to my attention and please do not hesitate to contact me should you need any further information.
Re: Regulation 28 Report to Prevent Future Deaths – Juanita Boate Nti who died on 9 September 2020.
Thank you for your Report to Prevent Future Deaths (hereafter “Report”) dated Friday 18 August 2023 concerning the death of Juanita Boate Nti on 9 September 2020. In advance of responding to the specific concerns raised in your Report, I would like to express my deep condolences to Juanita’s parents and family. NHS England are keen to assure the family and the coroner that the concerns raised about Juanita’s care have been listened to and reflected upon.
Your Report raises the concern that clinical practice errors were made regarding the prescription of and dispensing of oral morphine preparation to be administered to Juanita. Further, that the error would not have occurred had the lower strength of morphine been a choice on the EMIS prescription service and that the whole of the NHS should ensure local health economy wide paediatric prescribing policies.
NHS England is aware that in the last three years, there have unfortunately been three serious incidents where an incorrect oral morphine preparation was prescribed and dispensed to a baby. We are aware that issues have included a lack of awareness and clarity over a medicine being a special preparation as well as poor communication between medical professionals and with the parents of the child.
National work is underway by paediatric experts to consider what needs to be done to reduce the likelihood of a recurrence. This work incorporates several related workstreams including a specials formulary, with standardisation of strengths of paediatric oral liquids, recognition in NHS payment schemes, national guidelines, standardisation of RAG lists1 and a national approach and input into GP Prescribing systems, including using the NHS dictionary of medicines and devices (dm+d) codes for special prescriptions. The dm+d is a dictionary of descriptions and codes which represent medicines and devices in use across the NHS. It must be used when electronic systems exchange or share information about medicines relating directly to a patient’s care. I note from your Report that EMIS have already placed the special prescription on its drug data base.
1 RAG stands for red, amber, green and the RAG List provides professional guidance for practitioners in both primary and secondary care as to where responsibility should sit for prescribing. National Medical Director NHS England Wellington House 133-155 Waterloo Road London SE1 8UG
13 November 2023
The national Patient Safety Team at NHS England are aware of the issues and the Royal College of Paediatrics and Child Health (RCPCH) and the Neonatal and Paediatric Pharmacy Group (NPPG) Joint Medicines Committee is currently undertaking a ‘Review of the Management of the Supply of Unlicensed Liquid Medicines to Children’, which includes the workstreams referenced above. NHS England awaits a statement from the Group as to next steps later in November 2023, and further actions and discussions will then then take place. We can update the Coroner once we have an update. NHS England also understands that the Advisory Council on the Misuse of Drugs’ Technical Committee is reviewing the safety of liquid morphine and will carefully consider outcomes and recommendations arising from this. There is also national guidance from the National Institute for Health and Care Excellence (NICE) on End of life care for infants, children and young people with life- limiting conditions and guidance on the use of morphine in palliative care and young children: Morphine | Drugs | BNF | NICE At a more regional level, a Patient Safety Learning Bulletin was circulated across South East London by South East London Clinical Commissioning Group (since replaced by South East London Integrated Care Board (ICB)) following this incident. This included key learning points relating to prescribing and dispensing of unlicensed specials. A ‘Specials Team’ has also been established which works across the whole health system and has incorporated work relating to the outcomes of the Serious Incident Report that reviewed the circumstances of Juanita’s death. Broader work on the EMIS formulary is also progressing with the ICB’s Children and Young People’s Formulary Team to rationalise the number of oral liquid options from which products can be chosen. Other London systems have also undertaken work in this area, for example North East London have undertaken local work to align their internal formulary against the national list of recommended strength specials in 2019, and updated these again in 2021: Standardised strengths of liquid medicines for children – NPPG.
The London region Controlled Drugs Accountable Officer will also be discussing this issue with all London ICB medications safety representatives and ensure regional oversight of implementation of action plans which will include communications to GPs and community pharmacists.
NHS England is also aware that of work being undertaken in other regions, including the North East, on this issue.
I would also like to provide further assurances on national NHS England work taking place around the Reports to Prevent Future Deaths. All reports received are discussed by the Regulation 28 Working Group, comprising Regional Medical Directors, and other clinical and quality colleagues from across the regions. This ensures that key learnings and insights around preventable deaths are shared across the NHS at both a national and regional level and helps us pay close attention to any emerging trends that may require further review and action.
Thank you for bringing these important patient safety issues to my attention and please do not hesitate to contact me should you need any further information.
Sent To
- NHS England
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56-Day Deadline
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Source: Courts and Tribunals Judiciary
Report Sections
Investigation and Inquest
On 9th September 2020 Miss Juanita Boate Nti (ref 9210617), died aged 4 months, in a Paediatric Intensive Care Unit. A post mortem examination was conducted, indicating an overdose of morphine. An inquest was opened on 10th March 2021 and concluded on 27th July 2023. The medical cause of death was found to be 1a Townes-Brocks syndrome with tracheal stenosis and complex congenital heart disease, following accidental morphine overdose.
Circumstances of the Death
Juanita was born on 12th May 2020 and investigations determined that her complex congenital diseases were not treatable. She received palliative care from 1st July and was tenderly cared for by her parents at home with a symptom management plan devised by specialists, which included Morphine solution via her naso-gastric tube as needed.
On 3rd September her condition suddenly deteriorated after a dose of morphine and she suffered a respiratory arrest on the way to hospital. She improved with urgent medication to reverse the effect of morphine intoxication, but went on to require intubation. She breathed regularly on pressure support but could not sustain spontaneous ventilation after extubation.
Neither the Symptom Control Plan nor prescription written by the GP, just before a Bank Holiday during the pandemic, stipulated the volume of morphine solution to be administered and although the correct dose was stated, in error two concentrations were on the prescription. The pharmacist did not notice the error and failed to write the volume of the solution to be administered.
She died of a combination of natural disease and accident. The failures of both the GP and pharmacist to make further enquiries to ensure the medication administration was safe related in part to the workload pressures of the pandemic. But they contributed to the death, as the child was given twenty times the intended dose. Juanita was very fragile with limited life expectancy, but would not have died when she did, without the overdose, naturally having less reserve to recover from the intoxication.
On 3rd September her condition suddenly deteriorated after a dose of morphine and she suffered a respiratory arrest on the way to hospital. She improved with urgent medication to reverse the effect of morphine intoxication, but went on to require intubation. She breathed regularly on pressure support but could not sustain spontaneous ventilation after extubation.
Neither the Symptom Control Plan nor prescription written by the GP, just before a Bank Holiday during the pandemic, stipulated the volume of morphine solution to be administered and although the correct dose was stated, in error two concentrations were on the prescription. The pharmacist did not notice the error and failed to write the volume of the solution to be administered.
She died of a combination of natural disease and accident. The failures of both the GP and pharmacist to make further enquiries to ensure the medication administration was safe related in part to the workload pressures of the pandemic. But they contributed to the death, as the child was given twenty times the intended dose. Juanita was very fragile with limited life expectancy, but would not have died when she did, without the overdose, naturally having less reserve to recover from the intoxication.
Action Should Be Taken
Local partnership work between hospital, general practice and pharmacies has led to revised repeat prescription polices, improved standard operating procedures, a revised paediatric formulary and overall improved safety of paediatric prescribing.
One of the paediatricians involved in the tragedy informed the court that a similar incident had occurred in North of England. He understood that the lessons of our fatal incident had not been applied there and that that there was a potential to prevent other deaths by ensuring that the whole of the NHS saw the benefits of local health economy wide paediatric prescribing policies.
One of the paediatricians involved in the tragedy informed the court that a similar incident had occurred in North of England. He understood that the lessons of our fatal incident had not been applied there and that that there was a potential to prevent other deaths by ensuring that the whole of the NHS saw the benefits of local health economy wide paediatric prescribing policies.
Copies Sent To
: , consultant paediatrician, The Royal College of Paediatrics and Child Health, The Royal College of General Practitioners and The Royal Pharmaceutical Society
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.