Darren Carrington: Prevention of future deaths report
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Date of report: 15/06/2018
Ref: 2024-0094
Deceased name: Darren Carrington
Coroner name: Veronica Hamilton-Deeley
Coroner Area: West Sussex, Brighton and Hove
Category: Alcohol, drug and medication related deaths
This report is being sent to: North laine Medical Centre | Clinical Commissioning Group
| REGULATION 28: REPORT TO PREVENT FUTURE DEATHS | |
|---|---|
| THIS REPORT IS BEING SENT TO: [REDACTED] North Laine Medical Centre, 12-14 Gloucester Street, Brighton [REDACTED], Practice Manager, North Laine Medical Centre, 12-14 Gloucester Street, Brighton [REDACTED] Clinical Commissioning Group, Hove Town Hall, Norton Road, Hove | |
| 1 | CORONER I am Veronica HAMILTON-DEELEY, Senior Coroner, for the City of Brighton and Hove |
| 2 | CORONERS LEGAL POWERS I make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. |
| 3 | INVESTIGATION and INQUEST On 18 th April 2018 I commenced an investigation into the death of Darren James CARRINGTON The investigation concluded at the end of the inquest on 6th June 2018. The conclusion of the inquest was MISADVENTURE BEING IMPULSIVE OVERDOSE WHILST UNDER THE INFLUENCE OF ALCOHOL (DRUG RELATED DEATH) |
| 4 | CIRCUMSTANCES OF THE DEATH I am enclosing a copy of the Record of Inquest and also the letter (without it’s annexures) from the Controlled Drug Liaison Officer for the City of Brighton and Hove, [REDACTED] which is self-explanatory |
| 5 | CORONER’S CONCERNS During the course of the inquest the evidence revealed matters giving rise to concern. In my opinion there is a risk that future deaths will occur unless action is taken. In the circumstances it is my statutory duty to report to you. The MATTER THAT I AM CONCERNED ABOUT is the method of prescribing medications such as Zopiclone [REDACTED] etc. to patients with a history which suggests that they either are or are very likely to be becoming dependent upon such medications or are misusing them. Examples of both the above would be too frequent requests for repeat prescriptions and information concerning and a history of overdoses. The Inquest discussed whether circumstances, including those outlined above should trigger an automatic/mandatory medication review conducted with the patient; consideration of a different prescribing period and very careful monitoring of the online requests for repeat prescriptions. Alternatively, there could be a ban on the requests for repeat prescriptions with the repeats simply being issued for an appropriate period of time “automatically”. In this case as you will see from [REDACTED] report, over twice the appropriate amount of Zopiclone was issued over a period of 57 days. The patient in question had Zopiclone present at a fatal level in his blood at the time of his collapse from which he never recovered. I remain very worried about these prescribing issues and about the fact that apparently receptionists and clinicians can override the warnings in the surgery’s computer system. I should like this to be carefully investigated and look forward to hearing with a response within the relevant time period. I realise that the situation may be exacerbated by GPs working part time and many part time practitioners being involved in the prescribing procedure as well as many receptionists being involved in it but if this is the trend then it seems to me the safeguards must be extended not made easier to override. The other ‘failsafe device’ is the dispensing pharmacist. When repeats are requested online there is a designated pharmacy. They receive emailed scripts. Their own systems should flag up cases of over or too frequent prescribing as well as other matters. |
| 6 | ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you AND your organisation have the power to take such action. |
| 7 | YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by August 4th 2018. I, the coroner may extend the period. Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise you must explain why no action is proposed. |
| 8 | COPIES and PUBLICATION I have sent a copy of my report to the Chief Coroner and to the following Interested Persons South East Coast Ambulance Service, [REDACTED] , Sussex Partnership NHS Foundation Trust 3. [REDACTED] Secretary of State for Health, Department of Health [REDACTED], Chief Executive, NHS England [REDACTED], NHS England South (South East) [REDACTED], Gordons Solicitors [REDACTED], Boots UK Limited I have also sent it to:- [REDACTED], General Pharmaceutical Council [REDACTED],CQC [REDACTED], Sussex Police Who may find it useful or of interest. I am also under a duty to send the Chief Coroner a copy of your response. The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. You may make representations to me, the coroner, at the time of your response, about the release or the publication of your response by the Chief Coroner. |
| 9 | 15 June 2018 |