Date of report: 26/10/2023
Deceased name: Jacqueline Carrey
Coroner name: Tom Osborne
Coroner Area: Milton Keynes
Category: Alcohol, drugs medication related deaths, Care Home Health related deaths
This report is being sent to: Milton Keynes University Hospital
|REGULATION 28 REPORT TO PREVENT DEATHS|
|THIS REPORT IS BEING SENT TO: |
Milton Keynes University Hospital Chief Executive
I am Tom OSBORNE, Senior Coroner for the coroner area of Milton Keynes
|2||CORONER’S 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 01 June 2023 I commenced an investigation into the death of Jacqueline Anne CARREY aged 56. The investigation concluded at the end of the inquest on 18 October 2023.
The conclusion of the inquest was:
|4||CIRCUMSTANCES OF THE DEATH |
The deceased was admitted to Milton Keynes University Hospital on the 11th May 2023 due to extreme pain from pancreatitis. She was discharged from hospital on the 16th May 2023 with an excess of [REDACTED] medication despite warnings recorded that her medication should be restricted to seven days supply. She was found deceased at home Milton Keynes on the 25th May 2023 and the cause of death was [REDACTED] toxicity.
|5||CORONER’S CONCERNS |
During the course of the investigation my inquiries revealed matters giving rise to concern. In my opinion there is a risk that future deaths could occur unless action is taken. In the circumstances it is my statutory duty to report to you.
The MATTERS OF CONCERN are as follows:
There may not have been a clear indication on the patients medical record about the potential risk of [REDACTED] abuse, or for the risk to be flagged up to members of staff before discharge. This oversight raises serious questions about the hospital’s processes and procedures for managing [REDACTED] medication and patient records. I strongly urge the hospital to undertake a comprehensive review of the procedures concerning the distribution of [REDACTED] medication. It is imperative that the hospital ensures that the potential risks and warnings are clearly marked on the patient’s medical record and that all staff are made aware of any potential concerns regarding [REDACTED] use. I believe that a thorough review of your procedures and the implementation of more robust protocols can protect the well being of patients and prevent future similar deaths.
|6||ACTION SHOULD BE TAKEN|
In my opinion action should be taken to prevent future deaths and I believe you (and/or your organisation) have the power to take such action.
You are under a duty to respond to this report within 56 days of the date of this report, namely by December 21, 2023. 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
I have also sent it to [REDACTED] (sister of Mrs. CARREY), Chief Executive of Milton Keynes University Hospital and the Care Quality Commission.
who may find it useful or of interest.
I am also under a duty to send a copy of your response to the Chief Coroner and all interested persons who in my opinion should receive it.
I may also send a copy of your response to any person who I believe may find it useful or of interest.
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.
Tom OSBORNE Senior Coroner for Milton Keynes