Kerry Jacobs
PFD Report
All Responded
Ref: 2014-0133
All 1 response received
· Deadline: 16 May 2014
Coroner's Concerns (AI summary)
The hospital lacked a policy requiring doctors to document reasons for prescribing medication outside BNF guidelines. There was also no protocol for pharmacists and clinicians to discuss queried medication dosages.
View full coroner's concerns
_ _ (1) There was nothing within Mrs Jacobs' hospital records indicating any awareness that she had been prescribed steroid dose which was out with usual ENT practice and the BNF guidelines_ Nor was the actual prescription issued confirmed with or reported to patient's consultant: The evidence was that there is no policy or procedure within the Trust which requires a doctor who prescribes a medication outside usual practice andlor BNF guidelines to note within the patient's clinical record that have made deliberate decision to do so and to record their grounds for so deciding 5981872.1 being The day leg and leg: and 95mg the they
(2) There was no discussion between the pharmacist and either the prescribing doctor or the patient's consultant regarding the dosage when the query was raised by the pharmacist was informed by the consultant physician who conducted the SUI that; where pharmacist queries the intended prescription of a drug; it is good practice for the clinician and pharmacist to discuss the matter and consider together the risks and benefits of the prescription. He stated that it "would clearly be of value" to have a protocol requiring such a discussion to take place, where practicable. The Trust has no such protocol. consider that; although did not find that Mrs Jacobs' death would have been prevented by correction of her prescription, there is a risk that future deaths may occur in similar circumstances and action should be taken to reduce the risk that the prescription of an unintentionally high dose of a drug is not identified and corrected.
(2) There was no discussion between the pharmacist and either the prescribing doctor or the patient's consultant regarding the dosage when the query was raised by the pharmacist was informed by the consultant physician who conducted the SUI that; where pharmacist queries the intended prescription of a drug; it is good practice for the clinician and pharmacist to discuss the matter and consider together the risks and benefits of the prescription. He stated that it "would clearly be of value" to have a protocol requiring such a discussion to take place, where practicable. The Trust has no such protocol. consider that; although did not find that Mrs Jacobs' death would have been prevented by correction of her prescription, there is a risk that future deaths may occur in similar circumstances and action should be taken to reduce the risk that the prescription of an unintentionally high dose of a drug is not identified and corrected.
Responses
Action Taken
The Chief Medical Officer issued a directive for staff to record the rationale for prescribing medication outside of BNF guidance, and the Chief Pharmacist has reiterated the medication screening procedure to pharmacy staff, instructing direct discussion between prescribing doctor and dispensing pharmacist. (AI summary)
The Chief Medical Officer issued a directive for staff to record the rationale for prescribing medication outside of BNF guidance, and the Chief Pharmacist has reiterated the medication screening procedure to pharmacy staff, instructing direct discussion between prescribing doctor and dispensing pharmacist. (AI summary)
View full response
Dear Ms Dolan Thank you for your letter dated 25 March 2014,and the enclosed Regulation 28 Report to Prevent Future Deaths, following the Inquest into the death of Kerry Jacobs_ The Trust has taken the Regulation 28 Report very seriously and is keen to implement the changes that will prevent a similar event from happening again. note from your Report the two areas of concern arising from the Inquest; and submit the Trust's formal response to these issues as follows:
1. There is no policy or procedure within the Trust which requires a doctor who prescribes medication outside usual practice and / or BNF guidelines to note within the patient's clinical record that have made the deliberate decision to do so and to record their grounds for so deciding: Response: It is correct that there is no formal Trust policy in place, however_ Chief Medical Officer, has issued a directive to the Chiefs of Service in the Divisions (see attached email dated 4 June 2014) that all staff should record and specify the rationale for the decision to prescribe a medication dosage that is outside guidance within BNF , or usual practice. In addition, when a query is raised by a pharmacist regarding patient s prescription, an must be made within the patient's medical records, noting the discussion and outcome. This directive will be disseminated to the clinical staff within each Division, at Multi Disciplinary Team (MDT) meetings each week, and departmental meetings; and will be added to the Trust's Audit Programme for 2014/2015. It is the Trust's expectation, and it is set down in the health professionals' Codes of Conduct; that when prescribing medication to patient the decision is based upon the patient's clinical diagnosis, symptoms, with reference to the BNF guidance, and based upon the clinicians' expertise, and knowledge of the patient Putting people first An Associated University Hospital of Delivering excellent; accessible healthcare Brighton and Sussex Medical School they entry
2 There is no policy or procedure within the Trust that requires discussion between the prescribing doctor and the dispensing pharmacist;, if and when there is a query regarding a prescription of a Response:_It is correct there is no formal Trust policy in place, however_ Chief Pharmacist; has re-iterated the medication screening procedure to the Trust's Pharmacy Technicians and Pharmacists attach copy of his email communication dated May 2014 in which he specifically has instructed the Pharmacy Department that "the prescribing clinician and the screening and dispensing pharmacist must have an inter-professional direct discussion about the prescription (not via secretaries) , and if the prescribing clinician is not available, then the pharmacy technician or pharmacist must speak to another prescriberl clinician who is able to make a decision:" has informed me that he has shared the above together with contact information for the Trust's Lead Pharmacists with the CCG Lead Pharmacists and GP practices_ in an email communication and the "GP newsletter" so they may inform community pharmacists of the Trust's procedure Please see the attached email correspondences dated 27 and 29 May 2014. The Trust is conscious that the prescription of steroids did not cause or contribute to the death in this case, but hope you are satisfied with the actions that have been taken and that the risk of future deaths occurring in similar circumstances is reduced.
1. There is no policy or procedure within the Trust which requires a doctor who prescribes medication outside usual practice and / or BNF guidelines to note within the patient's clinical record that have made the deliberate decision to do so and to record their grounds for so deciding: Response: It is correct that there is no formal Trust policy in place, however_ Chief Medical Officer, has issued a directive to the Chiefs of Service in the Divisions (see attached email dated 4 June 2014) that all staff should record and specify the rationale for the decision to prescribe a medication dosage that is outside guidance within BNF , or usual practice. In addition, when a query is raised by a pharmacist regarding patient s prescription, an must be made within the patient's medical records, noting the discussion and outcome. This directive will be disseminated to the clinical staff within each Division, at Multi Disciplinary Team (MDT) meetings each week, and departmental meetings; and will be added to the Trust's Audit Programme for 2014/2015. It is the Trust's expectation, and it is set down in the health professionals' Codes of Conduct; that when prescribing medication to patient the decision is based upon the patient's clinical diagnosis, symptoms, with reference to the BNF guidance, and based upon the clinicians' expertise, and knowledge of the patient Putting people first An Associated University Hospital of Delivering excellent; accessible healthcare Brighton and Sussex Medical School they entry
2 There is no policy or procedure within the Trust that requires discussion between the prescribing doctor and the dispensing pharmacist;, if and when there is a query regarding a prescription of a Response:_It is correct there is no formal Trust policy in place, however_ Chief Pharmacist; has re-iterated the medication screening procedure to the Trust's Pharmacy Technicians and Pharmacists attach copy of his email communication dated May 2014 in which he specifically has instructed the Pharmacy Department that "the prescribing clinician and the screening and dispensing pharmacist must have an inter-professional direct discussion about the prescription (not via secretaries) , and if the prescribing clinician is not available, then the pharmacy technician or pharmacist must speak to another prescriberl clinician who is able to make a decision:" has informed me that he has shared the above together with contact information for the Trust's Lead Pharmacists with the CCG Lead Pharmacists and GP practices_ in an email communication and the "GP newsletter" so they may inform community pharmacists of the Trust's procedure Please see the attached email correspondences dated 27 and 29 May 2014. The Trust is conscious that the prescription of steroids did not cause or contribute to the death in this case, but hope you are satisfied with the actions that have been taken and that the risk of future deaths occurring in similar circumstances is reduced.
Sent To
- Surrey and Sussex NHS Trust
Response Status
Linked responses
1 of 1
56-Day Deadline
16 May 2014
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 19 March 2014 concluded the inquest into the death of MRS KERRY JACOBS born 11June 1969 (aged 44 yrs), who died on July 2013. determined that Mrs Jacobs had died as a result of (1a) a pulmonary embolism arising from (1b) deep vein thrombosis in the right calf and that her death was from a natural cause.
Circumstances of the Death
Mrs Jacobs suffered with progressive hearing loss and tests suggested that she probably had an auto-immune disorder putting her at risk of becoming deaf. Her treating Consultant ENT surgeon sought advice from a Consultant Otologist and a Consultant Oncologist; it was determined that 'high dose' steroids (prednisolone) should be prescribed to her for a four week period, tapering off thereafter . The advice, as recorded in typed note, was for starting dose of Imglkg od. ENT consultant stated in evidence at the inquest that; in accordance with BNF guidelines, he considered that the maximum appropriate prednisolone dose was 60mg od. However it was an ENT speciality doctor , rather than the ENT Consultant who next saw Mrs Jacobs in outpatients_ He stated that he had discussed Mrs Jacobs' case with the consultant before the appointment The specialty doctor prescribed prednisolone od. for four weeks to then be reduced to 75 mg od. This dosage was based on his understanding that Mrs Jacobs weight was 95kg: He stated that he had previously prescribed up to 6Omg prednisolone and had never prescribed steroids at as high dosage as od, however he knew of high dose steroids being given for a different disorder (myasthenia gravis) and he understood that he was following the consultants" recommendation. The speciality doctor did not recognise at the material time that he was prescribing outside BNF guidelines_ The
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.
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.