Susan Perry
PFD Report
All Responded
Ref: 2022-0382
Alcohol, drug and medication related deaths
Wales prevention of future deaths reports (2019 onwards)
All 1 response received
· Deadline: 23 Jan 2023
Coroner's Concerns (AI summary)
Medication cupboard keys were left in easily accessible, unlocked locations nearby, compromising medication security and creating a significant risk of service users accessing and misusing drugs.
View full coroner's concerns
During the inquest the evidence revealed matters giving rise to concern. In my opinion there is a risk that future deaths will occur unless action is taken.
(1) I received evidence from her support workers that service user's medications were kept in locked cupboards on the ground floor. However, the keys to the same were kept either in an unlocked drawer nearby, or in a pot on an adjacent, or nearby work surface. I sought clarification upon this and evidence to determine if this arrangement was still in place today. Whilst I did not receive any evidence per se on this matter, the indication I received from counsel for MIRUS Wales did not satisfy me, that arrangements for access to this cupboard had been altered or revised since Susan Perry’s death on 23.10.20.
(2) My concern is simply that these arrangements give rise to a risk that a service user could access medication (their own, or other service users) from the locked cupboards by opening the same using the nearby keys, defeating the purpose of securing the medication. Deliberate, or inadvertent administration of such medication could well lead to the death of that individual.
(3) I believe that MIRUS Wales operate several similar supported accommodation concerns across South Wales, and I received no evidence to satisfy me that practices & procedures were in place across these concerns to address this risk of self-harm.
(1) I received evidence from her support workers that service user's medications were kept in locked cupboards on the ground floor. However, the keys to the same were kept either in an unlocked drawer nearby, or in a pot on an adjacent, or nearby work surface. I sought clarification upon this and evidence to determine if this arrangement was still in place today. Whilst I did not receive any evidence per se on this matter, the indication I received from counsel for MIRUS Wales did not satisfy me, that arrangements for access to this cupboard had been altered or revised since Susan Perry’s death on 23.10.20.
(2) My concern is simply that these arrangements give rise to a risk that a service user could access medication (their own, or other service users) from the locked cupboards by opening the same using the nearby keys, defeating the purpose of securing the medication. Deliberate, or inadvertent administration of such medication could well lead to the death of that individual.
(3) I believe that MIRUS Wales operate several similar supported accommodation concerns across South Wales, and I received no evidence to satisfy me that practices & procedures were in place across these concerns to address this risk of self-harm.
Responses
Action Taken
Mirus Wales has taken action by removing key storage from unlocked locations and reinforcing medication policies and training. (AI summary)
Mirus Wales has taken action by removing key storage from unlocked locations and reinforcing medication policies and training. (AI summary)
View full response
Dear Graeme Hughes (HM Senior Coroner)
Re: Prevention of Future Death report following inquest into the death of Susan Jane Perry.
Further to your letter dated 29th November 2022 concerning the Regulation 28 Report to prevent Future Deaths and your requirement for me to respond to your concerns in relation to:
(1) I received evidence from her support workers that service user's medications were kept in locked cupboards on the ground floor. However, the keys to the same were kept either in an unlocked drawer nearby, or in a pot on an adjacent, or nearby work surface. I sought clarification upon this and evidence to determine if this arrangement was still in place today. Whilst I did not receive any evidence per se on this matter, the indication I received from counsel for MIRUS Wales did not satisfy me, that arrangements for access to this cupboard had been altered or revised since Susan Perry’s death on
23.10.20.
(2) My concern is simply that these arrangements give rise to a risk that a service user could access medication (their own, or other service users) from the locked cupboards by opening the same using nearby keys, defeating the purpose of securing the medication. Deliberate, or inadvertent administration of such medication could well lead to the death of that individual.
(3) I believe that MIRUS Wales operate several similar supported accommodation concerns across South Wales, and I received no evidence to satisfy me that practices & procedures were in place across these concerns to address this risk of self-harm.
Actions taken to prevent further incidents from occurring
mirus possibilities into realities Registered Address: mirus Wales, Unit 5, Cleeve House, Lambourne Crescent, Llanishen, Cardiff. CF14 5GP Tel: 029 20236216, Email: admin@mirus-wales.org.uk , Website: www.mirus-wales.org.uk Registered Charity
• mirus has reviewed its medication policy, procedures, and practice in relation to the handling of keys. (Action completed 5th December 2022)
Within the policy we have reworded the expectations of ‘key holders’
"Where the requirement is for medication to be in locked storage, as identified by the Medication risk assessment; arrangements must be in place for keys to be kept on the nominated medication key holder's person at all times".
• We have instructed managers to conduct an observation of practice to all staff who have responsibility to administer medication by the end of December
2022.
• The content of the medication training for staff and managers has been updated to strengthen the additional measures for handling of keys to ensure safe storage and prevent unauthorised access to medication. (Action taken 5th December 2022)
• Additional quality assurance measures will follow to ensure that the above actions have been implemented. (Action by end of February 2023)
The above measures will be subject to full scrutiny at our leadership meetings and at the next full Board of Trustee meeting in March 2023.
The incident was previously reported to the Charity Commission, and we have since provided them with a further update and shared your findings with them.
Trustees have been fully briefed on the incident and the outcome of the coroner's inquest on 12th December 2022 a full Board of Trustee meeting.
We have notified Care Inspectorate Wales (CIW) at the time of Susan Jane Perry’s death and have provided updates of the incident and the outcome of the inquest to them. (See attached serious incident form and updates). In addition to this, we have notified Cardiff Social Services commissioning authority of the incident and the outcome of the inquest. (See attached serious incident form and updates). Should you require any further evidence of the actions taken please let me know as soon as possible.
Re: Prevention of Future Death report following inquest into the death of Susan Jane Perry.
Further to your letter dated 29th November 2022 concerning the Regulation 28 Report to prevent Future Deaths and your requirement for me to respond to your concerns in relation to:
(1) I received evidence from her support workers that service user's medications were kept in locked cupboards on the ground floor. However, the keys to the same were kept either in an unlocked drawer nearby, or in a pot on an adjacent, or nearby work surface. I sought clarification upon this and evidence to determine if this arrangement was still in place today. Whilst I did not receive any evidence per se on this matter, the indication I received from counsel for MIRUS Wales did not satisfy me, that arrangements for access to this cupboard had been altered or revised since Susan Perry’s death on
23.10.20.
(2) My concern is simply that these arrangements give rise to a risk that a service user could access medication (their own, or other service users) from the locked cupboards by opening the same using nearby keys, defeating the purpose of securing the medication. Deliberate, or inadvertent administration of such medication could well lead to the death of that individual.
(3) I believe that MIRUS Wales operate several similar supported accommodation concerns across South Wales, and I received no evidence to satisfy me that practices & procedures were in place across these concerns to address this risk of self-harm.
Actions taken to prevent further incidents from occurring
mirus possibilities into realities Registered Address: mirus Wales, Unit 5, Cleeve House, Lambourne Crescent, Llanishen, Cardiff. CF14 5GP Tel: 029 20236216, Email: admin@mirus-wales.org.uk , Website: www.mirus-wales.org.uk Registered Charity
• mirus has reviewed its medication policy, procedures, and practice in relation to the handling of keys. (Action completed 5th December 2022)
Within the policy we have reworded the expectations of ‘key holders’
"Where the requirement is for medication to be in locked storage, as identified by the Medication risk assessment; arrangements must be in place for keys to be kept on the nominated medication key holder's person at all times".
• We have instructed managers to conduct an observation of practice to all staff who have responsibility to administer medication by the end of December
2022.
• The content of the medication training for staff and managers has been updated to strengthen the additional measures for handling of keys to ensure safe storage and prevent unauthorised access to medication. (Action taken 5th December 2022)
• Additional quality assurance measures will follow to ensure that the above actions have been implemented. (Action by end of February 2023)
The above measures will be subject to full scrutiny at our leadership meetings and at the next full Board of Trustee meeting in March 2023.
The incident was previously reported to the Charity Commission, and we have since provided them with a further update and shared your findings with them.
Trustees have been fully briefed on the incident and the outcome of the coroner's inquest on 12th December 2022 a full Board of Trustee meeting.
We have notified Care Inspectorate Wales (CIW) at the time of Susan Jane Perry’s death and have provided updates of the incident and the outcome of the inquest to them. (See attached serious incident form and updates). In addition to this, we have notified Cardiff Social Services commissioning authority of the incident and the outcome of the inquest. (See attached serious incident form and updates). Should you require any further evidence of the actions taken please let me know as soon as possible.
Sent To
- MIRUS Wales
Response Status
Linked responses
1 of 1
56-Day Deadline
23 Jan 2023
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 2 November 2020 I commenced an investigation into the death of Susan Jane PERRY . The investigation concluded at the end of the inquest on 24.11.22 . The conclusion of the inquest was: The deceased died due to the indivisible contribution of COVID-19 infection and elevated levels of her prescription medication. In combination, these have likely led to central nervous system depression and her death. Her Cause of Death was found to be: 1a Mixed (Prescription) Drug Toxicity with Covid 19 Infection
1b 1c II
1b 1c II
Circumstances of the Death
These were recorded as : Susan Parry had a chronic complex mental ill health condition. In order to manage the same, she had required long-term care and support. At the time of her death, she was receiving the same at 21 Rockwood Avenue Llandaff. From around the 17th of October 2020, both her mental and physical health deteriorated. Posthumously, she was found to be infected with the COVID-19 virus. To manage her mental ill health, she was prescribed a range of medication which was slightly altered on the 20th of October 2020. During the week, she became more lethargic, remaining in her room. On the morning of the 23rd of October 2020, she was found deceased there by her support workers. Post-mortem examination, supported by toxicological analysis found that she had died due to a combination of mixed prescribed drug toxicity and COVID-19 infection. The Inquest focused upon: -
a. How she came to have such elevated levels of her prescription medication in her post-mortem blood samples and the contribution that may have had to her death. Whilst the precise causation of the same was not established on the evidence, it was found that neither she, nor her support workers had administered an overdose(s) of her medication deliberately, or accidentally. It was found, on a balance of probabilities, that the elevated levels were more likely to have their causation in post-mortem re-distribution and/or the instability of the medication for the purposes of toxicological testing. .
a. How she came to have such elevated levels of her prescription medication in her post-mortem blood samples and the contribution that may have had to her death. Whilst the precise causation of the same was not established on the evidence, it was found that neither she, nor her support workers had administered an overdose(s) of her medication deliberately, or accidentally. It was found, on a balance of probabilities, that the elevated levels were more likely to have their causation in post-mortem re-distribution and/or the instability of the medication for the purposes of toxicological testing. .
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.