Jane Walker: Prevention of future deaths report

Alcohol, drug and medication related deathsOther related deaths

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Date of report: 13/03/2024

Ref: 2024-0137

Deceased name: Jane Walker

Coroner name: Kate Robertson

Coroner Area: North West Wales

Category: Other related deaths | Alcohol, drug and medication related deaths

This report is being sent to: Home Office

The Rt Honourable James Cleverly, Secretary of State for the Home Office
I am Kate Robertson, HM Senior Coroner for North West Wales
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.
On 11 August 2020 an investigation was commenced into the death of Jane Walker (DOB 3 April 1968) who died on 8 August 2020. The investigation concluded at the end of the inquest on 13 March 2024. The conclusion of the inquest was accident.
The circumstances of the death are as follows :
On 8 August 2020 Jane Walker was a passenger on a rigid inflatable boat on the Menai Straits when a collision occurred between the rigid inflatable boat and a jet ski. Jane suffered significant internal injuries, was attended to by paramedics at the slip way and then conveyed to hospital, where she later died. The circumstances were investigated by the Marine Accident Investigation Branch.
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 MATTERS OF CONCERN are as follows
Jane was administered morphine for pain relief at the slip way by the paramedics. Administering such opioid medication takes time in that a cannula must first be inserted and once administered the morphine can take up to 15 minutes to be effective.
Evidence was heard at the Inquest that there are alternative analgesics which can be administered much more quickly, have a much quicker impact and can be easier to remove when required. Example of such is mucosal fentanyl lozenge. This can be administered by placing the lozenge (on a stick) into the patient’s mouth, which takes effect very quickly and which can be removed quickly if required. It can be considered a safe and rapid method of delivering pre-hospital analgesia and is used by the military. It is not, however, available to paramedics.
I am concerned that the unavailability of such analgesics to paramedics (in England as well as Wales) to assist patients who require immediate pain relief in the context of it reducing stress on the body, providing easier and potentially faster extrication and patient handling, and improving breathing, where time is of the essence for medical treatment, to reflect a risk of deaths into the future.
Pursuant to controlled drug legislation paramedics are not currently permitted to administer such analgesics. Whilst matters of health are devolved to Wales, controlled drug legislation in this context is not a devolved matter to Wales, hence this Report to the Home Secretary. I am aware that The Medicines Act 1968 and/or other controlled drug legislation would require amendment to allow paramedics to administer such analgesia.
In my opinion action should be taken to prevent future deaths and I believe you 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 8 May 2024. I, Kate Robertson, 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.
I have sent a copy of my report to the Family of the Deceased and to the Chief Coroner. I have also sent a copy of this Report to the Chief Executive of the Welsh Ambulance Service Trust for his information.
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.
9Dated 13 March 2023
Kate Robertson
HM Senior Coroner for North West Wales