Fred Whittaker
PFD Report
Partially Responded
Ref: 2016-0249
Coroner's Concerns (AI summary)
A patient was erroneously re-prescribed medication due to the lack of a system for recording reasons for stopping drugs and poor prescription management, a risk potentially widespread in GP practices.
View full coroner's concerns
An important issue in the Inquest was the continued prescription of Clonazepam by the Heaton Moor Medical Centre despite the written request on 17ih August 2015, from Mr Whittaker's treating psychiatrist; that this medication be stopped: The evidence given to me by_ a partner at the Heaton Moor Medical Centre, suggests that although the prescription was stopped it was started again in error_ advised thatl a) On receipt of request the drug was moved from the Repeat Prescription list to the Past Prescription list, without any reference in the records of the reason as t0 why the Clonazepam was being stopped. b) On Or about the 19" August 2015 the pharmacy which administered Mr Whittaker's medications requested & repeat prescription c) It was likely that upon receiving that request Clonazepam was simply moved back on to the repeat prescription by one of the doctors at the Practice on being advised by an administrator of the Pharmacy's request: This is clearly an unacceptable error. accept that; on this occasion, this error played no part in Mr Whittaker's demise but it is not difficult to imagine completely different set of circumstances where such an error would give rise to a risk of death_ evidence was that there were no standard directions as to how to manage this as a situation and that other practices may adopt the same simple policy of transferring the drug from one Iist to another: In my opinion there is a risk that future deaths will occur unless action is taken: That Heaton Moor Medical Centre does not have a mechanism whereby the reasons or requests or decisions that a patient is no longer to be prescribed a particular drug are recorded in the clinical records That this poor practice may not be limited to Heaton Moor Medical Centre and is replicated in many GP practices in the Northwest and indeed, nationally:
Responses
Action Planned
NHS England has been assured that the practice involved undertook a review and will do a significant event analysis. NHS England will share learning and best practice with GPs and the Medical Director will write to all GPs in Greater Manchester to share learning and to medicine management teams to provide support to practices. (AI summary)
NHS England has been assured that the practice involved undertook a review and will do a significant event analysis. NHS England will share learning and best practice with GPs and the Medical Director will write to all GPs in Greater Manchester to share learning and to medicine management teams to provide support to practices. (AI summary)
View full response
Dear Mr Bridgman, RE: Fred Whittaker NHS England Regulation 28 Report Response Thank you for your letter dated 14 July 2016 regarding your Regulation 28 Report following your investigation and inquest into the death of Mr Fred Whittaker: On behalf of NHS England would like to express our sympathy to Mr Whittaker's family: NHS England is a single national organisation and Medical Director for Greater Manchester is professionally accountable to me This letter is NHS England's single response on behalf of both of us and trust you will find this acceptable_ You have raised the following concern for NHS England to respond to: "NHS England should draw attention of all GP practices this potential for the inadvertent re-prescription of discontinued medications and to take steps to ensure the risks are reduced to its minimum or negated:' AlI GP practices in England have electronic clinical systems to support them in the delivery of their care of patients. Within the patient record there is the ability to record both acute (i.e. one off) and regular 'repeat' prescriptions. When repeat prescription is generated, the reason or diagnosis for the medication should be recorded. Similarly, when a repeat medication is stopped, the reason for stopping the medication should be recorded in the clinical records: In the guidance published by the Department of Health, Responsibility for prescribing between hospitals and GPs EL (91) 127, 1991 (enclosed) makes it clear that the legal responsibility for prescribing lies with the doctor who signs the prescription: The issue of any prescription and the subsequent doctor's signature is to assure the dispensing pharmacist that the doctor considers the medication to be appropriate and necessary to treat that patient, giving due regard to dose, High quality care for all, now and for future generations RECEIVED 2016 SEP
strength, duration, formulation and interactions with other medication or with the patient's physiology: In this instance the prescribing GP should have been alerted to the fact the medication requested by the pharmacy had in fact been stopped by the patient's consultant: have been assured by my colleague Medical Director NHS England, that the practice and GPs involved have undertaken an appropriate review, are planning to undertake thorough significant event analysis and have put into place appropriate measures to prevent a recurrence of a similar event_ has informed me that he will raise this regulation 28 report and our response at the Quality Surveillance Group that has oversight of the quality of health and social care in Greater Manchester: He is writing to all GPs in Greater Manchester to share learning from this tragic event and to remind them of their responsibilities when prescribing for patients, especially when making changes, stopping and starting medicines He is also writing to the medicine management teams of the Greater Manchester Clinical Commissioning Groups to ask them to provide relevant advice and support to practices. Additionally, NHS England will share this learning and best practice further with GPs. trust this response addresses the concern as detailed in your report and thank you for bring this important matter to my attention
strength, duration, formulation and interactions with other medication or with the patient's physiology: In this instance the prescribing GP should have been alerted to the fact the medication requested by the pharmacy had in fact been stopped by the patient's consultant: have been assured by my colleague Medical Director NHS England, that the practice and GPs involved have undertaken an appropriate review, are planning to undertake thorough significant event analysis and have put into place appropriate measures to prevent a recurrence of a similar event_ has informed me that he will raise this regulation 28 report and our response at the Quality Surveillance Group that has oversight of the quality of health and social care in Greater Manchester: He is writing to all GPs in Greater Manchester to share learning from this tragic event and to remind them of their responsibilities when prescribing for patients, especially when making changes, stopping and starting medicines He is also writing to the medicine management teams of the Greater Manchester Clinical Commissioning Groups to ask them to provide relevant advice and support to practices. Additionally, NHS England will share this learning and best practice further with GPs. trust this response addresses the concern as detailed in your report and thank you for bring this important matter to my attention
Sent To
- Heaton Moor Medical Centre
- NHS England
Response Status
Linked responses
1 of 2
56-Day Deadline
8 Sep 2016
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 2nd November 2015 an investigation was commenced into the death of Fred Whittaker who died at his home address on 25" October 2015. The investigation concluded with an Inquest held on 8" July 2016. The conclusion of the Inquest was: Narrative: Mr Whittaker died from the combined effects of developing bronchopneumonia and the consumption of excessive amounts of codeine, methadone and alcohol: Medical cause of death Ia Bronchopneumonia and combined Codeine, Methadone and Alcohol Toxicity Cirrhosis of the Liver due to Alcoholism and Hepatitis C; Type 2 Diabetes Mellitus; Hypertensive Heart Disease
Circumstances of the Death
Mr Whittaker was a 37 year old gentleman diagnosed with schizophrenia who was also known to abuse drugs, namely benzodiazepines, codeine and alcohol, In the early hours of the 24th October 2015 Mr Whittaker summoned an ambulance as he was having chest pains feeling drowsy. He was taken to Accident and Emergency at Stepping Hill Hospital where he first admitted taking two codeine tablets with & large amount of alcohol: He later admitted to having taken four pots of methadone. Naloxone was administered by infusion and his GCS by 8.40am had returned to 15. At about 9.30am Mr Whittaker removed his cannula for the Naloxone infusion. At 11.01 am Mr Whittaker self-discharged and went home. He was seen by a support worker at about 12.3Opm; he was noted to be well and did not appear to be under the influence of drugs or alcohol_He was_given his prescribed medication for_that and day
On the morning of the 25th October 2015 Mr Whittaker was found dead in his bed at his flat;
On the morning of the 25th October 2015 Mr Whittaker was found dead in his bed at his flat;
Action Should Be Taken
In my opinion action should be taken by Heaton Moor Medical Centre to develop a system such the risk of the inadvertent re-prescription of discontinued medications is reduced t0 its minimum or negated. In my opinion NHS England should draw to the attention of all GP practices this potential for the inadvertent re-prescription of discontinued medications and to take steps to ensure risks are reduced to its minimum or negated:
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.