Stephen Coulson
27 Oct 2017 · Coroner Rashid Sohail · Manchester (City)
This report repeats 1 earlier warning, and was raised again 2 times later. See the linked reports.
The coroner's concerns
1. inadequate controlled drug administration
“the system in place for the administration, documentation and audit of processes associated with the use of controlled drugs”
2. failure to escalate observation needs
“the lack of escalation of the need to admit patients for observation and review should they fulfil the criteria to require continued observation / review prior to discharge”
3. resistance to learning from investigation
“the witness did not accept that any lessons could be learnt from the investigation surrounding the death of the deceased”
Linked reports
Closely relatedConfidence 0.80 · moderate
Earlier report
“not all CQC Outcomes were considered at the last inspection, purportedly because they did not have anyone available to inspect and review the drugs administration system at the material time”
This report
“Controlled drugs - the system in place for the administration, documentation and audit of processes associated with the use of controlled drugs”
Closely relatedConfidence 0.92 · high
This report
“the system in place for the administration, documentation and audit of processes associated with the use of controlled drugs”
Later report
“The audit checking of controlled drugs by The Boots Company PLC is not robust in that there is no double check in place in relation to the audit checking procedure followed by Boots”
Closely relatedConfidence 0.90 · high
This report
“the system in place for the administration, documentation and audit of processes associated with the use of controlled drugs”
Later report
“processes had been such that it was not easily identified that drugs were not accounted for e.g. Stock sheets were inaccurate”
Responses
2017-0307-Response-by-CQC.pdf ↗· Care Quality Commission
Stated action · between October and December 2018
“The policy was updated in November 2017 to include reference to an opioid patch monitoring form. The use of the form should minimise the risk of a similar incident experienced by Mr [name redacted] being repeated. The trust managers have informed the Commission that they plan to audit implementation of the form. We will monitor this through our quarterly engagement meetings and subsequently consider this at the next inspection, which is likely to take place between October and December 2018.”
2017-0307-Response-by-NHS-England.pdf ↗· NHS England
Stated action
“The Trust has now implemented an extensive action plan, they have: e Updated the Trust Controlled Drug Policy to include reference to the Opiate Patch Monitoring Form to ensure that the clinical team are aware of the opiate patches worn and administration date.”