Joseph Page

PFD Report Historic (No Identified Response) Ref: 2018-0347
Date of Report 12 November 2018
Coroner Graeme Hughes
Coroner Area South Wales Central
Response Deadline est. 7 June 2019
Hospital Death (Clinical Procedures and medical management) related deaths
Judiciary.uk Report PDF
Coroner's Concerns (AI summary)
Hospital policies for storing patients' own medication were breached, allowing a patient unsupervised access to prescription drugs which led to an overdose.
View full coroner's concerns
(1) In the Emergency Department; and whilst patients were awaiting admission to a Ward, their PODS remained with them unsecured in a bay (or similar) . Exposing the medication to potential further uselmis-use by the patient; another patient or relative, or theft and mis-use (2) On ward B5, the policies in place at the time in relation to PODS were not followed, allowing Mr Page's medication to remain unsecured on the Ward, exposing the medication as in (1) above. (3)
Sent To
  • Cardiff & Vale University Health Board
Response Status
Linked responses 0 of 1
56-Day Deadline 7 Jun 2019
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
commenced an investigation on the 28h March 2018 into the death of Joseph Page: The Investigation concluded at the end of the inquest on 5th November 2018. The conclusion was "Suicide" and the medical cause of death was 1a. Multi-Organ Failure Ib. Hypotension Ic. Mixed Toxicity
Circumstances of the Death
These were recorded as Joseph had a number of significant co-morbidities, most notably chronic kidney disease and ischaemic cardiomyopathy: He was experiencing declining health, which led to him admitted to University Hospital Wales on 15.3.18. He was responding well to treatment; when, ad on 22.3.18, he received some upsetting news in relation to the health of one of his daughters. At; or around 1.45am on 23.3.18 he has deliberately taken a mixed overdose of his prescription medication: That medication was accessible to him; & not locked away in his bedside medicine cupboard contravening the hospital's Medicines Code & patient property policies. Despite treatment thereafter he declined significantly from around 8am, and likely suffered multi-organ failure, consequent upon hypotension and overdose. He died at around 9.30am that day: The Inquest focused uponx - The practices & procedures in place at University Hospital Wales Cardiff both in the Emergency Department and Ward B5 for receiving; utilising & storing Patients Own Drugs (PODS) whilst in hospital
b. The treatment received by Mr Page post overdose
Action Should Be Taken
In my opinion action should be taken t0 prevent future deaths and believe you and your organisation have the power to take such action.
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.