Natalie Edgington
PFD Report
All Responded
Ref: 2021-0008
All 1 response received
· Deadline: 8 Mar 2021
Coroner's Concerns (AI summary)
Prescribers issued methadone without sufficient information on the patient's liver disease, relying on self-reporting and failing to consider a lower starting dose.
View full coroner's concerns
During_the course_of_the inquest_the_evidence revealed matters_giving_rise to concern. In my the 1a) history opinion there is a risk that future deaths will occur unless action is taken. : That prescribers should have full information about the nature and extent of a service user's liver disease in order to ensure that prescribing is within safe limits_ The prescription to the Deceased was issued without relevant medical information that could have been obtained from the GP andlor an up to date liver function test: There is a risk associated with reliance on service users self-reporting of his/her own medical history particularly against background of non-attendance at medical appointments. The BNF recommends that consideration should be given to starting patients with history of liver disease on a lower dose of methadone than the standard starting dose of 3Omls There was no evidence to suggest that any consideration was given to starting the Deceased on a lower dose_
Responses
Action Taken
Turning Point has updated its Opioid Substitution Therapy (OST) policy to include new requirements for prescribers, published a reminder to clinical staff on prescribing OST safely, and provided every team with an NHS.net email address. A national audit will take place in June 2021 to assess the impact of the learning. (AI summary)
Turning Point has updated its Opioid Substitution Therapy (OST) policy to include new requirements for prescribers, published a reminder to clinical staff on prescribing OST safely, and provided every team with an NHS.net email address. A national audit will take place in June 2021 to assess the impact of the learning. (AI summary)
View full response
Turning Point The Exchange 3 New York Street TURNING Manchester M14HN POINT
Inspired by possibility
Her Majesty's Area Coroner Ms Catherine McKenna The Phoenix Centre L/Cpl Stephen Shaw MC Way Heywood Oll0 lLR
5th March 2021 Madam, Natalie Jane Edgington Your reference: 68821 Response to Regulation 28 Report to Prevent Future Deaths I write in response to the Regulation 28 Report to Prevent Future Deaths (PFD) dated 11 January 2021 in which you highlighted two concerns which arose during the inquest into the death of Ms Edgington. In what follows I set out the actions that have been taken by Turning Point in relation to your concerns. We were not an Interested Person in this inquest and therefore have not had full disclosure of all evidence before the Court which led to your concerns. However, I hope that this letter provides reassurance that Turning Point takes your concerns very seriously, has thoroughly reviewed the issues raised and has taken appropriate measures to ensure the risk of any future death connected with these issues is minimised as far as possible. Concerns That prescribers should have full information about the nature and extent of a service user's liver disease in order to ensure that prescribing is within safe limits. The prescription to the Deceased was issued without relevant medical information that could have been obtained from the GP and/or an up to date liver function test. There is a risk associated with reliance on a service users self-reporting of his/her own medical history particularly against a background of non-attendance at medical appointments The BNF recommends that consideration should be given to starting patients with a history ofliver disease on a lower dose of methadone than the standard starting dose of 30mls. There was no evidence to suggest that any consideration was given to starting the Deceased on a lower dose. t!J&I disability ri1 G1 confident INVESTOR IX PEOPLE COMMITTED CHIEF EXECUTIVE:
TURNING POINT IS A REGISTERED CHARITY, NO. 234887, A REGISTERED SOCIAL LANDLORD AND A COMPANY LIMITED BY GUARANTEE NO. 793558 (ENGLAND & WALES REGISTERED OFFICE: STANDON HOUSE, 21_MANSELL STREET, LONDON, El SAA.
Turning Point The Exchange 3 New York Street TURNING Manchester M14HN POINT
inspired by possibility
Response Please find below the actions that we have taken within the organisation in relation to your concerns.
1) We have produced an educational support pack on "The effects of hepatic dysfunction on the metabolism of methadone". I attach a copy of this document for your information. This was distributed on 26 January 2021 to all staff within the organisation who have a clinical role in relation to the treatment of substance misuse. Whilst the document as a whole is relevant to the concerns raised, I highlight particularly the recommendations for staff at page 6 of the document which include the following: " • start low and go slow with methadone titrations" " • obtain a copy of the Summary Care Record (SCR) from the GP Practice prior to the Initial Medical Assessment {IMA}" " • Consider the LFT results and other biochemical tests from the GP but understand their limitations: they should not be viewed in isolation. In general in the context of LFTs and other biochemical tests, drug modification in liver disease should be considered if o the prothrombin time >130% of normal or o if bilirubin >100µmol/L" " • Ensure the client understands how to recognise symptoms of liver dysfunction and clinicians can recognise them. If they present review the client as a matter of urgency and respond appropriately"
2) We are producing a Multiple Choice Question (MCQ) assessment of the educational support pack referred to in point 1. This assessment will be rolled out at the end of March 2021 and will be monitored through the clinical supervision structure to ensure that the learning has been cascaded and embedded through all relevant sections of the organisation.
3) (Clinical Director) and (Chief Pharmacist) hosted a clinical session on prescribing Opioid Substitute Treatment (OST) (which includes methadone) safely on Thursday 14 January 2021. In attendance at this session was at least one clinician and one operational representative from every service under the Turning Point umbrella with the aim that that clinician then cascaded the learning within their own service (please see point 4 for further support for this process). Key points from this session included:
• Ensuring a Summary Care Record (SCR) is available at the Initial Medical Assessment (IMA) by requesting as early as possible from the GP Practice
• If a SCR is not available at the IMA, prescribers should follow up any clinical concerns presented at the IMA with the GP Practice prior to prescribing. Please note the absence of an IMA does not preclude prescribing but prescribers must make a case- by-case judgement based on the presentation and its clinical complexity. E!Jrll disability m!iconfident IN\'ESTOR IN PEOPLE COMMITTED CHIEF EXECUTIVE:
TURNING POINT IS A REGISTERED CHARllY, NO. 234887, A REGISTERED SOCIAL LANDLORD AND A COMPANY LIMITEO BY GUARANTEE NO. 793558 (ENGLAND & WALES REGISTERED OFFICE: STANDON HOUSE, 21 MANSELL STREET, LONDON, El SAA.
Turning Point The Exchange 3 New York Street TURNING Manchester M14HN POINT
inspired by possibility
• Titration schedules must be reflective of the clinical case and not necessarily the same for all clients
4) The Turning Point Public Health and Substance Misuse Senior Clinical Governance Group published within their January 2021 monthly clinical brief a reminder to all clinical staff on prescribing OST safely. I attach a copy of this document for your information. You will see that the key areas included in this brief which are relevant to your concerns reflect those as set out in point 3 above.
5) Turning Point will carry out a national audit across all substance misuse services in relation to the medical information available to an OST prescriber at the point of prescription and the documentation of considerations/actions taken pending receipt of background information. This audit will take place in June 2021 to assess the impact of the learning as set out above.
6) We have made arrangements to provide every team within the organisation with an NHS.net email address. The work was completed on 14th October 2020. This ensures that data can be shared securely and efficiently between Turning Point and NHS bodies/employees (such as a GP surgery). I hope that the above has provided the necessary reassurances following your concerns. Thank you for raising them and I hope that I have demonstrated that Turning Point takes very seriously any concerns that are raised about the care and treatment of its service users. Please do let me know on the details below if any of the above fails to provide the necessary reassurance or if it would assist to discuss any aspect further.
Inspired by possibility
Her Majesty's Area Coroner Ms Catherine McKenna The Phoenix Centre L/Cpl Stephen Shaw MC Way Heywood Oll0 lLR
5th March 2021 Madam, Natalie Jane Edgington Your reference: 68821 Response to Regulation 28 Report to Prevent Future Deaths I write in response to the Regulation 28 Report to Prevent Future Deaths (PFD) dated 11 January 2021 in which you highlighted two concerns which arose during the inquest into the death of Ms Edgington. In what follows I set out the actions that have been taken by Turning Point in relation to your concerns. We were not an Interested Person in this inquest and therefore have not had full disclosure of all evidence before the Court which led to your concerns. However, I hope that this letter provides reassurance that Turning Point takes your concerns very seriously, has thoroughly reviewed the issues raised and has taken appropriate measures to ensure the risk of any future death connected with these issues is minimised as far as possible. Concerns That prescribers should have full information about the nature and extent of a service user's liver disease in order to ensure that prescribing is within safe limits. The prescription to the Deceased was issued without relevant medical information that could have been obtained from the GP and/or an up to date liver function test. There is a risk associated with reliance on a service users self-reporting of his/her own medical history particularly against a background of non-attendance at medical appointments The BNF recommends that consideration should be given to starting patients with a history ofliver disease on a lower dose of methadone than the standard starting dose of 30mls. There was no evidence to suggest that any consideration was given to starting the Deceased on a lower dose. t!J&I disability ri1 G1 confident INVESTOR IX PEOPLE COMMITTED CHIEF EXECUTIVE:
TURNING POINT IS A REGISTERED CHARITY, NO. 234887, A REGISTERED SOCIAL LANDLORD AND A COMPANY LIMITED BY GUARANTEE NO. 793558 (ENGLAND & WALES REGISTERED OFFICE: STANDON HOUSE, 21_MANSELL STREET, LONDON, El SAA.
Turning Point The Exchange 3 New York Street TURNING Manchester M14HN POINT
inspired by possibility
Response Please find below the actions that we have taken within the organisation in relation to your concerns.
1) We have produced an educational support pack on "The effects of hepatic dysfunction on the metabolism of methadone". I attach a copy of this document for your information. This was distributed on 26 January 2021 to all staff within the organisation who have a clinical role in relation to the treatment of substance misuse. Whilst the document as a whole is relevant to the concerns raised, I highlight particularly the recommendations for staff at page 6 of the document which include the following: " • start low and go slow with methadone titrations" " • obtain a copy of the Summary Care Record (SCR) from the GP Practice prior to the Initial Medical Assessment {IMA}" " • Consider the LFT results and other biochemical tests from the GP but understand their limitations: they should not be viewed in isolation. In general in the context of LFTs and other biochemical tests, drug modification in liver disease should be considered if o the prothrombin time >130% of normal or o if bilirubin >100µmol/L" " • Ensure the client understands how to recognise symptoms of liver dysfunction and clinicians can recognise them. If they present review the client as a matter of urgency and respond appropriately"
2) We are producing a Multiple Choice Question (MCQ) assessment of the educational support pack referred to in point 1. This assessment will be rolled out at the end of March 2021 and will be monitored through the clinical supervision structure to ensure that the learning has been cascaded and embedded through all relevant sections of the organisation.
3) (Clinical Director) and (Chief Pharmacist) hosted a clinical session on prescribing Opioid Substitute Treatment (OST) (which includes methadone) safely on Thursday 14 January 2021. In attendance at this session was at least one clinician and one operational representative from every service under the Turning Point umbrella with the aim that that clinician then cascaded the learning within their own service (please see point 4 for further support for this process). Key points from this session included:
• Ensuring a Summary Care Record (SCR) is available at the Initial Medical Assessment (IMA) by requesting as early as possible from the GP Practice
• If a SCR is not available at the IMA, prescribers should follow up any clinical concerns presented at the IMA with the GP Practice prior to prescribing. Please note the absence of an IMA does not preclude prescribing but prescribers must make a case- by-case judgement based on the presentation and its clinical complexity. E!Jrll disability m!iconfident IN\'ESTOR IN PEOPLE COMMITTED CHIEF EXECUTIVE:
TURNING POINT IS A REGISTERED CHARllY, NO. 234887, A REGISTERED SOCIAL LANDLORD AND A COMPANY LIMITEO BY GUARANTEE NO. 793558 (ENGLAND & WALES REGISTERED OFFICE: STANDON HOUSE, 21 MANSELL STREET, LONDON, El SAA.
Turning Point The Exchange 3 New York Street TURNING Manchester M14HN POINT
inspired by possibility
• Titration schedules must be reflective of the clinical case and not necessarily the same for all clients
4) The Turning Point Public Health and Substance Misuse Senior Clinical Governance Group published within their January 2021 monthly clinical brief a reminder to all clinical staff on prescribing OST safely. I attach a copy of this document for your information. You will see that the key areas included in this brief which are relevant to your concerns reflect those as set out in point 3 above.
5) Turning Point will carry out a national audit across all substance misuse services in relation to the medical information available to an OST prescriber at the point of prescription and the documentation of considerations/actions taken pending receipt of background information. This audit will take place in June 2021 to assess the impact of the learning as set out above.
6) We have made arrangements to provide every team within the organisation with an NHS.net email address. The work was completed on 14th October 2020. This ensures that data can be shared securely and efficiently between Turning Point and NHS bodies/employees (such as a GP surgery). I hope that the above has provided the necessary reassurances following your concerns. Thank you for raising them and I hope that I have demonstrated that Turning Point takes very seriously any concerns that are raised about the care and treatment of its service users. Please do let me know on the details below if any of the above fails to provide the necessary reassurance or if it would assist to discuss any aspect further.
Sent To
- Turning Point
Response Status
Linked responses
1 of 1
56-Day Deadline
8 Mar 2021
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 27 February 2020, commenced an investigation into death of Natalie Jane Edgington. The investigation concluded at the end of the inquest on 11 January 2021 when returned Narrative Conclusion, The Deceased died as a result of a complication of prescribed medication; The medical cause of death was: Methadone toxicity 1b) Fatty liver disease
2) Liver cirrhosis
2) Liver cirrhosis
Circumstances of the Death
Natalie Edgington was 28 years old when she died at her mothers address on 24 February 2020. Ms Edgington had of chronic liver disease and had been discharged from Gastroenterology services in October 2019 due t0 her non-attendance at liver clinic appointments The Deceased was on repeat prescription for codeine phosphate for abdominal pain secondary to liver problems and the evidence was that consideration had previously been given to the prescription of spironolactone for ascites_ On 8 January 2020,cthe Deceased self-referred to Turning Point in Rochdale for support with opiate dependency_ She was assessed by a nurse prescriber who noted her chronic liver disease and wrote to her GP on 22 January 2020 requesting any recent blood tests_ There is no evidence tat the GP responded to this letter or that a liver function test was requested by Turning Point On 29 January 2020, the Deceased was prescribed titrating dose of methadone progressing from 30 mls to 60 mls over the course of 9 to 12 days. The Deceased's mother contacted Turning Point on 11 February 2020 to inform them that the Deceased had been vomiting for 5 days and was too unwell to collect her methadone Alternative arrangements were made for the collection of the prescriptions_ The Deceased did not attend an appointment that was offered by the GP on 11 February or respond to a message left by her recovery worker on 20 February: The Deceased was found dead at her mother's address on 24 February 2020. She died of the effects of an accumulation of methadone which she had been unable to properly eliminate due to an impairment of her liver function.
Action Should Be Taken
In my opinion action should be taken to prevent future deaths and believe each of you respectively have the power to take such action.
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.