Ania Sohail
7 Feb 2023 · Coroner Catherine McKenna · Manchester North
A similar concern from this report was raised again 1 time later. See the linked reports.
The coroner's concerns
1. excessive medication quantities
“Whilst each individual pharmacy had in-house safety checks to safeguard against over prescribing by their own pharmacy, there is no integrated system in place which would alert a prescriber to prescriptions that have been dispensed by other on-line pharmacies. As a result, it is currently possible for a patient to obtain excessive quantities of medication by simply placing multiple orders with different on-line pharmacists.”
2. lack of information sharing
“There is no requirement for the on-line pharmacies to share information with the patient's GP. This means that, in the absence of the patient's consent to share information, the online prescriber is reliant on the accuracy and truthfulness of the history provided by the patient.”
3. contraindicated medication prescribing
“Lack of information sharing also creates a risk that a GP or Pharmacist Prescriber may unwittingly prescribe a medication that is contraindicated with a medication that has been dispensed through an on-line pharmacy.”
4. inaccurate consent information
“The Recovery & Discharge Plans contained inaccurate information regarding [the deceased]'s consent to share information with her mother. The evidence was that this was an entry made in error in June 2020 and was not picked up by any of the nurses who updated the Recovery & Discharge Plan over the subsequent 11 months.”
5. unaddressed online medication procurement risk
“The Recovery & Discharge Plans did not address the risks associated with [the deceased]'s procurement of Propranolol from on-line pharmacies. The evidence was that an update of the Recovery & Discharge Plan involved members of nursing staff simply adding a note that the overdoses had taken place. The Plan did not show that any meaningful thought had been given to addressing the particular risk associated with the procurement of on-line medication.”
6. lack of mandatory refresher training
“Mandatory refresher training on basic aspects of nursing care such as record keeping, searches, care-planning, undertaking pre- and post-leave assessments and confidentiality is not provided to staff.”
Linked reports
Closely relatedConfidence 0.90 · high
This report
“There is no requirement for the on-line pharmacies to share information with the patient's GP. This means that, in the absence of the patient's consent to share information, the online prescriber is reliant on the accuracy and truthfulness of the history provided by the patient.”
Later report
“The need for online prescribers to be able to access a patient's records (at least the Summary Care Records). These records could be attached to the consultation for review by the prescriber.”
Responses
2023-0046-Response-from-Department-of-Health-and-Social-Care.pdf ↗· Department of Health and Social Care
Stated action · January 2024
“The Trust has subsequently been the subject of an NHS England-commissioned independent investigation into the failings within the Trust's services reported at the Edenfield Centre and the failure within the organisation to appropriately manage concerns and mitigate against patient harm. The investigation's final report was published in January 2024 and notes that Griffin Ward has now been closed. The Trust has developed an improvement plan, which was updated to reflect the findings of the independent”
2023-0046-Response-from-Greater-Manchester-Mental-Health.pdf ↗· Greater Manchester Mental Health NHS Foundation Trust
Stated action · end of May
“The Recovery and Discharge Plan that was in place prior to the incident [the deceased]'s death is no longer used by GMMH and has been replaced by the care plan document that is used in all other inpatient areas of the Trust. This document is called the ATAC (Acute Triage and Assessment Care Plan). A local audit of care plans will be undertaken by the ward manager by the end of May to ensure learning is embedded and consent is evidenced in the care plans.”
Stated action · February 2023
“During the Trust review, following [the deceased]'s death, it was unclear whether all staff were aware that [the deceased] was buying medications from online Pharmacies or that this was an easily accessible way to obtain medication. In response, GMMH have created a Safety Briefing regarding the use of online pharmacies and Propranolol, aimed at communicating to staff the risks associated with the procurement of medication via online Pharmacies and the General Medical Councils 'ten principles' around online purchas”
Stated action · January
“The Trust has developed an inpatient 'Care Bundle - Leave from inpatient units'. The care bundle provides guidance to staff when supporting service users who are inpatients to access leave into the community and return to the ward safely. The care bundle prompts staff to complete pre and post-leave assessments and where to document these. This care bundle has been shared with all inpatient staff through established communication systems and was featured in the Patient safety Newsletter in”
Stated action
“As part of the Inpatient Leave Care Bundle, outlined in point 3, pre and post leave assessments should be recorded in the clinical record, including any reason to search a person following leave. The Trust Search Policy includes clear guidance on what should be recorded when a search is undertaken and whether anything was found or not.”
Stated action
“The current Trust observation policy does have a 1:5 minute recording sheet that requires a signature every 5 minutes. This has now been adopted by the service and its completion is audited by the ward manager as a minimum weekly.”
Stated action
“The Trust is currently undertaking a review of our Observation policy and practices through a task and finish working group which to date has reviewed best practice standards and guidance on the management and practice of therapeutic observations & engagement including the review of any digital innovations to support practice.”