Lewis Begley
PFD Report
All Responded
Ref: 2022-0380
All 1 response received
· Deadline: 20 Jan 2023
Coroner's Concerns (AI summary)
The mental health hospital lacked a proper record of stored medication, especially drugs subject to misuse, and had no system to track patient access or provide fixed overdose treatment training for doctors.
View full coroner's concerns
1. Evidence was heard that medication is kept in a locked room and in locked cabinets, in accordance with legislation. However, there is no record kept as to what medication is stored and how much, particularly which is a drug subject to misuse, in a mental health hospital where many patients have a history of drug misuse and suicidal ideation and actively seek out the drugs cupboard.
2. On a patient accessing medication, there is no knowledge as to whether anything has been taken and if so, how much, thereby limiting knowledge as to what treatment is to be considered and what action to be taken
3. Evidence was heard that there is no fixed training given to doctors with regard to the administering of in the event of there being a suspected drugs overdose.
2. On a patient accessing medication, there is no knowledge as to whether anything has been taken and if so, how much, thereby limiting knowledge as to what treatment is to be considered and what action to be taken
3. Evidence was heard that there is no fixed training given to doctors with regard to the administering of in the event of there being a suspected drugs overdose.
Responses
Action Planned
Norfolk and Suffolk NHS Foundation Trust is revising its Medicines Management Policy, led by a new Chief Pharmacist, to address stock oversight. They will not train medics to administer Naloxone due to infrequent use. (AI summary)
Norfolk and Suffolk NHS Foundation Trust is revising its Medicines Management Policy, led by a new Chief Pharmacist, to address stock oversight. They will not train medics to administer Naloxone due to infrequent use. (AI summary)
View full response
Dear Ms Lake Regulations 28 and 29 (2013) notification made in response to the death of Lewis Begley. I write to you in respect of Lewis Begley who died in December 2020. His inquest was held in September 2022, at the end of the inquest you raised concerns outlined in this response within a prevention of future deaths notification. I would like to reiterate to you and importantly to Lewis’s family our sincere regret and apologies for the death of Lewis whilst under our care. The concerns you raised are outlined below with our trust response to each point:
1. Evidence was heard that medication is kept in a locked room and in locked cabinets, in accordance with legislation. However, there is no record kept as to what medication is stored and how much, particularly which is a drug subject to misuse, in a mental health hospital where many patients have a history of drug misuse and suicidal ideation and actively seek out the drugs cupboard. We have recently employed a new Chief Pharmacist in the trust who has already begun improvement work in this area her initial action plan includes:
• Medicines Management Policy to be revised, implemented and monitored across the trust.
• Safe and Secure Handling of medication audit will now be led by Pharmacy, this is a change in process and accountability and address the issues of stock oversight in ward areas.
• Audit action plan will be developed for each clinical area together with nursing and pharmacy team.
• Pharmacy to support Medicines Management Efficacy &Treatment at ward level.
• All staff complete Medicines Management training as Statutory and Mandatory training.
2. On a patient accessing medication, there is no knowledge as to whether anything has been taken and if so, how much, thereby limiting knowledge as to what treatment is to be considered and what action to be taken As above. Trust Management Main Administration Block Hellesdon Hospital Drayton High Road Norwich NR6 5BE 17th November 2022 Ms Jacqueline Lake Norfolk Coroner’s Service County Hall Martineau Lane Norwich NR1 2DH
3. Evidence was heard that there is no fixed training given to doctors with regard to the administering of in the event of there being a suspected drugs overdose. In line with other mental health trusts, we will continue to train staff and stock as part of the resuscitation response adhering to the Resuscitation Council UK guidelines, both nurses and medics are able to administer this drug to reverse a suspected or known opiate overdose.
In respect of l and in line again with other mental health trust we will continue to stock
as a potential antidote to a suspected or known overdose; in case there is a medic available who is experienced and able to administer. However, we will not train our medics to administer this as the skill cannot be maintained without regular use. To note in our internal review the ambulance trust advised that the ambulance crews and paramedics do not administer this drug unless they have a specialist medic on the team for the same reason.
Please note the guidance below:
BNF “ should only be administered by, or under the direct supervision of, personnel experienced in its use. Use of the can be hazardous, particularly in mixed overdoses involving antidepressants or in
-dependent patients. may prevent the need for ventilation, particularly in patients with severe respiratory disorders; it should be used on expert advice only and not as a diagnostic test in patients with a reduced level of consciousness.”
Maudsley Practice Guidelines for Physical Heath Conditions in Psychiatry by David Taylor et al “ can be hazardous because of risks of precipitating seizures and ventricular arrythmias. It should only be used by people with previous experience of its use (or in the presence of people with experience).” “In the UK it is only licensed for reversal of sedative effects of in anaesthesia, other clinical procedures, or in intensive care. The main focus of managing suspected overdose should be to resuscitate according to ABCDE approach and transfer care to emergency services.”
I hope that this response answers your concerns, the sad death of Lewis was not anticipated however we apologise that we did not have the robust systems in place at that time which would have enabled staff to ascertain what and how much medication he had acquired.
It is anticipated that in light of the Chief Pharmacists improvement plan our medication management systems will meet the necessary safety levels in the future providing confidence and resilience for all.
1. Evidence was heard that medication is kept in a locked room and in locked cabinets, in accordance with legislation. However, there is no record kept as to what medication is stored and how much, particularly which is a drug subject to misuse, in a mental health hospital where many patients have a history of drug misuse and suicidal ideation and actively seek out the drugs cupboard. We have recently employed a new Chief Pharmacist in the trust who has already begun improvement work in this area her initial action plan includes:
• Medicines Management Policy to be revised, implemented and monitored across the trust.
• Safe and Secure Handling of medication audit will now be led by Pharmacy, this is a change in process and accountability and address the issues of stock oversight in ward areas.
• Audit action plan will be developed for each clinical area together with nursing and pharmacy team.
• Pharmacy to support Medicines Management Efficacy &Treatment at ward level.
• All staff complete Medicines Management training as Statutory and Mandatory training.
2. On a patient accessing medication, there is no knowledge as to whether anything has been taken and if so, how much, thereby limiting knowledge as to what treatment is to be considered and what action to be taken As above. Trust Management Main Administration Block Hellesdon Hospital Drayton High Road Norwich NR6 5BE 17th November 2022 Ms Jacqueline Lake Norfolk Coroner’s Service County Hall Martineau Lane Norwich NR1 2DH
3. Evidence was heard that there is no fixed training given to doctors with regard to the administering of in the event of there being a suspected drugs overdose. In line with other mental health trusts, we will continue to train staff and stock as part of the resuscitation response adhering to the Resuscitation Council UK guidelines, both nurses and medics are able to administer this drug to reverse a suspected or known opiate overdose.
In respect of l and in line again with other mental health trust we will continue to stock
as a potential antidote to a suspected or known overdose; in case there is a medic available who is experienced and able to administer. However, we will not train our medics to administer this as the skill cannot be maintained without regular use. To note in our internal review the ambulance trust advised that the ambulance crews and paramedics do not administer this drug unless they have a specialist medic on the team for the same reason.
Please note the guidance below:
BNF “ should only be administered by, or under the direct supervision of, personnel experienced in its use. Use of the can be hazardous, particularly in mixed overdoses involving antidepressants or in
-dependent patients. may prevent the need for ventilation, particularly in patients with severe respiratory disorders; it should be used on expert advice only and not as a diagnostic test in patients with a reduced level of consciousness.”
Maudsley Practice Guidelines for Physical Heath Conditions in Psychiatry by David Taylor et al “ can be hazardous because of risks of precipitating seizures and ventricular arrythmias. It should only be used by people with previous experience of its use (or in the presence of people with experience).” “In the UK it is only licensed for reversal of sedative effects of in anaesthesia, other clinical procedures, or in intensive care. The main focus of managing suspected overdose should be to resuscitate according to ABCDE approach and transfer care to emergency services.”
I hope that this response answers your concerns, the sad death of Lewis was not anticipated however we apologise that we did not have the robust systems in place at that time which would have enabled staff to ascertain what and how much medication he had acquired.
It is anticipated that in light of the Chief Pharmacists improvement plan our medication management systems will meet the necessary safety levels in the future providing confidence and resilience for all.
Sent To
- Norfolk and Suffolk NHS Foundation Trust
Response Status
Linked responses
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56-Day Deadline
20 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 29 December 2020 I commenced an investigation into the death of Lewis Robert BEGLEY aged 35. The investigation concluded at the end of the inquest on 13 September 2022. The medical cause of death was: 1a) Central Nervous System and Respiratory Depression 1b) Combined Drug Toxicity 1c)
2) The conclusion of the inquest was: Misadventure and Neglect contributed to the cause of death.
2) The conclusion of the inquest was: Misadventure and Neglect contributed to the cause of death.
Circumstances of the Death
Mr Begley was placed on Section 2 of the Mental Health Act and admitted to Samphire Ward, Chatterton House on 12 December 2020. He was placed on 4 times per hour observations when in communal areas and general hourly observations when he was in his bedroom. Mr Begley was seen to be acting in a suspicious manner during the early hours of 15th December 2020 whilst in the communal area. On 15th December 2020, Mr Begley gained access to the medicine room between 02.29.04 and 02.29.23 and again between 02.31.10 and 02.45.51. Upon being found in the medicine room, there was a failure to escalate risk to relevant persons. In addition, consideration was not given to further safeguarding checks in ensuring Mr Begley's safety. Multiple policies and practices were not followed adequately including the: Therapeutic Observations Policy, Searching Policy, Management of Medicines Policy. Inaccurate and inadequate information was handed over to other members of staff on shift and coming on shift. On the morning of the 15th December 2020, Mr Begley was found unresponsive in his room. CPR was commenced by staff. Emergency Services attended and Mr Begley was pronounced dead at the scene. At post mortem, a split plastic bag, containing 2 in addition to other tablets of shape, colour and size which were unidentifiable, were found in Mr Begley's rectum.
Copies Sent To
Care Quality Commission (CQC)
Department of Health
HSIB
Healthwatch Norfolk
NHS ENGLAND (NHS IMPROVEMENT)
NSFT Legal Services
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.