UK Inquiry Tracker

Clive Miles

PFD Report All Responded Ref: 2019-0432

Date of Report 16 December 2019

Coroner Alison Mutch

Coroner Area Manchester (South)

Response Deadline est. 25 February 2020

Alcohol, drug and medication related deaths Community health care and emergency services related deaths

Judiciary.uk Report PDF

All 1 response received · Deadline: 25 Feb 2020

Coroner's Concerns (AI summary)

The deceased had a toxic combination of prescribed medications, raising concerns about the monitoring and management of multiple high-dose prescriptions.

Responses

NHS Stockport Clinical Commissioning Group NHS / Health Body

16 Dec 2019

Action Planned
Stockport CCG will remind all GPs across Stockport of the importance of recording clear and detailed notes explaining the basis on which any change to prescribing frequency has been made. (AI summary)

View full response

Dear Ms Mutch Mr Clive Miles (RIP) Regulation 28 I refer to your letter dated 16 December 2019 and acknowledge receipt of the Regulation 28 report in relation to this case: I was saddened to read of the circumstances of the death of Mr Miles and would ask that you pass on my sincere condolences to his family. You report concern in relation to the following: The decision to change the prescribing frequency from weekly to monthly and whether this was appropriate Limited evidence of risk assessment to support the decision Iam not aware of which GP practice the patient was registered at ad do not have access to this gentleman's consultation records: Therefore my response is not specific to this patient; rather it is based on the scenario of any patient in similar circumstances: I hope this will be acceptable: The decision to amend the frequency of prescribing is based on the clinician's judgement at the time of the consultation: Unfortunately, there is no standard risk assessment tool that is currently evidenced to be effective The tools that are available are either not specific enough or not sensitive enough. This essentially means that assessment of risk is a clinical

decision based on the clinician's perception at the time: For your reference I have included a link to a a report dated April 2018 entitled 'Accuracy of risk scales for predicting repeat self-harm and suicide: a multicentre, population-level cohort study using routine clinical data' which I hope will be useful to you:- httpsiLLwwwncbinlmnih gov Lpmclarticles/PMC5921289L Whenever a decision is made to amend prescribing frequency my expectation is that there would be a detailed consultation note to explain the reason for the change ad the factors considered in reaching that decision. Clearly if the notes in this case were lacking then there is a need for reflection at that practice; I have assumed that your report has also been shared with the practice concerned: You refer to the appropriateness of the decision to move to monthly prescribing; this is difficult point for me to address based on the information available to me: What I can say is that patients can spend a considerable time in managing the process of ordering and collecting weekly medications ad that this is often a factor in the request to change to monthly prescribing: Stockport CCG is committed to learning and with this case in mind I will ensure that all GPs across the Stockport patch are reminded of the importance of recording clear ad detailed notes explaining the basis on which any change to prescribing frequency has been made: Iam sorry that my response is not patient specific but I the information provided will be helpful to you and that you are satisfied that the issues raised within your report have been addressed:

Sent To

Stockport Clinical Commissioning Group

Response Status

Linked responses 1 of 1

56-Day Deadline 25 Feb 2020

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 3r June 2019 commenced an investigation into the death of Clive Miles_ The investigation concluded on the 29uh November 2019 and the conclusion was one of Drug Related death. The medical cause of death was Ia) Combined toxic effects of morphine, codeine and sertraline CIRCUMSTANCES OF THE DEATH On 31st May 2019 Clive Miles was found at his home address, 14 Laburnum There were no suspicious circumstances or evidence of third party involvement in his death: Medication packs prescribed to him were found at his address in addition to an empty oramorph box Toxicology found that he had a toxic amount of morphine, codeine and sertraline in his system: The conclusion of the pathologist was that this combination had caused his death. CQRONER'S CQNCERNS During the course of 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. In the circumstances it is my statutory duty to report to you: The MATTERS OF CONCERN are as follows. The inquest was told that previously Clive Miles had been changed to weekly prescriptions because he had overdosed on prescribed medication when on monthly prescriptions In the week before his death his General Practitioner had moved him back to monthly prescribing believing that the risk no longer existed based on a discussion with him about how he was at that time. There was limited evidence of any assessment of the risk or the need t0 change the prescribing pattern As a result he was in possession of a significantly increased Way: quantity of medication in comparison to amount he had been restricted to on weekly prescriptions. ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and believe you have the power to take such action_ YOUR RESPONSE You are under a duty to respond to this report within 56 of the date of this report, namely by 10* February 2020. !, the coroner, may extend the period. response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise you must explain why no action is proposed: COPIES and PUBLICATION have sent a copy of my report to the Chief Coroner and to the following Interested Persons namely Mrs Erica Miles, mother of the deceased, on behalf of the family, who may find it useful or of interest. am also under a duty to send the Chief Coroner a copy of your response The Chief Coroner may publish either or both in a complete or redacted or summary form: He may send a copy of this report to any person who he believes may find it useful or of interest You may make representations to me, the coroner, at the time of your response, about the release or the publication of your response by Chief Coroner. Alison Mutch OBE HM Senior Coroner Aks 16.12.2019 the days Your the IXi^

Circumstances of the Death

On 31st May 2019 Clive Miles was found at his home address, 14 Laburnum There were no suspicious circumstances or evidence of third party involvement in his death: Medication packs prescribed to him were found at his address in addition to an empty oramorph box Toxicology found that he had a toxic amount of morphine, codeine and sertraline in his system: The conclusion of the pathologist was that this combination had caused his death.

Action Should Be Taken

In my opinion action should be taken to prevent future deaths and believe you have the power to take such action_