Janice Davies
PFD Report
All Responded
Ref: 2018-0409
All 1 response received
· Deadline: 25 Feb 2019
Coroner's Concerns (AI summary)
Missing documented observations and pain scores before discharge, alongside absent formal guidance for prescribing oramorph to discharging patients, led to inconsistent and potentially inappropriate medication.
View full coroner's concerns
In the circumstances it is my statutory to report to you_ _ (1) There was an absence of documented (despite indicated) observations of the deceased post her doses of oramorph at around 13.55 hrs 15 40 hrs on 19.4.18.
(2) There was an absence of an updated documented pain score prior to discharge. Most significantly, on the evidence of would have been desirablelrequired to inform the prescribing clinician_ Jof the most appropriate prescription of oramorph to be given to the deceased upon discharge.
(3) Most significantly, there appeared, on the evidence_ to be an absence of formal guidance or instruction - written or otherwise to clinicians in the Accident Emergency Department regarding the prescribing of oramorph to discharging patients This would appear then to give rise to potential inconsistencies in the prescribing of oramorph to discharging patients_ Not only in terms of prescribed dosages, but also in respect of the extent of the supply. The deceased was prescribed 40 mls per day & given a supply lasting two weeks evidence was that in the absence of clear evidence as t0 the deceased'S tolerance to morphine, he would be uncomfortable with this dosage & supply: evidence was that a prescription of 20 mls per a supply for 5 days (then review by GP if symptoms persistedlto assess the patient's reaction to the oramoph) was more appropriate_in the circumstances
(2) There was an absence of an updated documented pain score prior to discharge. Most significantly, on the evidence of would have been desirablelrequired to inform the prescribing clinician_ Jof the most appropriate prescription of oramorph to be given to the deceased upon discharge.
(3) Most significantly, there appeared, on the evidence_ to be an absence of formal guidance or instruction - written or otherwise to clinicians in the Accident Emergency Department regarding the prescribing of oramorph to discharging patients This would appear then to give rise to potential inconsistencies in the prescribing of oramorph to discharging patients_ Not only in terms of prescribed dosages, but also in respect of the extent of the supply. The deceased was prescribed 40 mls per day & given a supply lasting two weeks evidence was that in the absence of clear evidence as t0 the deceased'S tolerance to morphine, he would be uncomfortable with this dosage & supply: evidence was that a prescription of 20 mls per a supply for 5 days (then review by GP if symptoms persistedlto assess the patient's reaction to the oramoph) was more appropriate_in the circumstances
Responses
Action Taken
The Health Board has developed a corrective action plan and implemented actions including a registered nurse reflection, a standard operating procedure for oral opioid medication use, and RRAILS discussions and audits. (AI summary)
The Health Board has developed a corrective action plan and implemented actions including a registered nurse reflection, a standard operating procedure for oral opioid medication use, and RRAILS discussions and audits. (AI summary)
View full response
Dear Mr Hughes RE: Regulation 28 Janice Davies Thank you for the correspondence in relation to the above Regulation 28 received on 28th December 2018, which details the areas of concern following the conclusion of the inquest held 14th December 2018. Please be assured that the Health Board has taken this matter extremely seriously, has learnt lessons following the investigation and the matters raised at the inquest into the circumstances of Mrs Davies' death: Comprehensive and robust action has been taken to minimise the risk of any recurrence_
1. Action taken to plan and monitor improvements A corrective Action Plan for Improvement has been developed which reflect the concerns identified within the Regulation 28 Report:
2. Actions Implemented A number of actions have been taken forward by the Health Board, the progress with these actions is reflected in the attached action plan which include:
1) The Registered nurse to personally reflect on the care given and the importance of undertaking observations and pain assessment following the administration of opioid medication.
2) A Standard Operating Procedure has been implemented to advise on the appropriate use of oral opioid medication in acute pain. A copy is attached.
3) This case has been discussed in the Rapid Response to Acute Illness (RRAILS) on 25th January 2019 and will be reviewed in the next RRAILS on 29th April 2019. The departmental manager to ensure score audits are undertaken. Return Address: Cwm Taf University Health Board, Headquarters, Navigation Park, Abercynon, CF4S 4SN Chair Cadeirydd; Professor Marcus Longley Chief Executive Prif Weithredydd: Mrs A Williams Cwm Tal University Health Board the operational name 0f the Cwm Taf University Health Board Bwrda lechyd Prifysgol Cwm Tal yw enw gwerhredol Bwrdd lechyd Prifysgol Cwm Tal pain
I sincerely hope that this information and enclosed Action Plan will reassure you that the Health Board has learnt important lessons from the investigation into the care provided to Mrs Davies and that effective action has now been taken to prevent further deaths; Iwould like to convey once again my deepest sympathy and sincere apologies to Mrs Davies' family for the failings identified.
1. Action taken to plan and monitor improvements A corrective Action Plan for Improvement has been developed which reflect the concerns identified within the Regulation 28 Report:
2. Actions Implemented A number of actions have been taken forward by the Health Board, the progress with these actions is reflected in the attached action plan which include:
1) The Registered nurse to personally reflect on the care given and the importance of undertaking observations and pain assessment following the administration of opioid medication.
2) A Standard Operating Procedure has been implemented to advise on the appropriate use of oral opioid medication in acute pain. A copy is attached.
3) This case has been discussed in the Rapid Response to Acute Illness (RRAILS) on 25th January 2019 and will be reviewed in the next RRAILS on 29th April 2019. The departmental manager to ensure score audits are undertaken. Return Address: Cwm Taf University Health Board, Headquarters, Navigation Park, Abercynon, CF4S 4SN Chair Cadeirydd; Professor Marcus Longley Chief Executive Prif Weithredydd: Mrs A Williams Cwm Tal University Health Board the operational name 0f the Cwm Taf University Health Board Bwrda lechyd Prifysgol Cwm Tal yw enw gwerhredol Bwrdd lechyd Prifysgol Cwm Tal pain
I sincerely hope that this information and enclosed Action Plan will reassure you that the Health Board has learnt important lessons from the investigation into the care provided to Mrs Davies and that effective action has now been taken to prevent further deaths; Iwould like to convey once again my deepest sympathy and sincere apologies to Mrs Davies' family for the failings identified.
Sent To
- Cwm Taf University Health Board
Response Status
Linked responses
1 of 1
56-Day Deadline
25 Feb 2019
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
commenced an investigation on the 31s October 2018 into the death of Janice Mary Davies. Investigation concluded at the end of the inquest on 14th December 2018. The conclusion was Drug Related (prescription) Accidental death and the medical cause of death was Ta. Morphine Toxicity and Bilateral Rib Fractures 1b. Mechanical Fall 2 Chronic Obstructive Pulmonary Disease and Chronic Kidney Disease
Circumstances of the Death
On 19.4.18 Janice Davies fell of bed at home sustaining fractured ribs. She attended the Royal Glamorgan Hospital that day, given 2 x Sml doses of oramorph, prescribed 4 x 1Omls oramorph daily a supply of around 2 weeks then, discharged home She was unable to tolerate the oramorph after around lunchtime on 20.4.18 and following medical advice from her GP switched to her usual pain killing medication CO-codamol and oxyNorm. Sometime thereafter; the concentration of morphine in her blood reached toxic level, likely contributed to by her undiagnosed chronic kidney disease (discovered at post mortem examination):. This has likely caused respiratory depression which on the_ backaround of impaired lung function has led to her death at home at jin the early hours of 21.4.18. In broad terms, the Inquest focused upon:- The appropriateness of the care provided to the deceased at Royal Glamorgan Hospital on 19.4.18 & from her GP on 20.4.18 The dosages of oramorph given & prescribed to the deceased at Royal Glamorgan Hospital. The observations of the deceased on 19.4.18 The discharging of the deceased on 19.4.18 The content of the advice (by telephone} given by her GP on 20.4.18 regarding her toleration of oramorph The causal effects of the dosages of oramorph in the setting of the posthumously identified chronic kidney disease out and
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:
Similar PFD Reports
Reports sharing organisations, categories, or themes
Related Inquiry Recommendations
Public inquiry recommendations addressing similar themes
Close HSS Dispute Resolution Procedure when HSSA opens
Post Office Horizon Inquiry
Inconsistent Healthcare Data Infrastructure
Proportionate Access to Linked Healthcare Records
COVID-19 Inquiry
Inconsistent Healthcare Data Infrastructure
Transfusion Performance Benchmarking
Infected Blood Inquiry
Inconsistent Healthcare Data Infrastructure
NHSBT Transfusion Outcome Funding
Infected Blood Inquiry
Inconsistent Healthcare Data Infrastructure
National Haemophilia Database Support
Infected Blood Inquiry
Inconsistent Healthcare Data Infrastructure
Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.