Raymond Watkins: Prevention of future deaths report

Hospital Death (Clinical Procedures and medical management) related deaths

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Date of report: 26/06/2024

Ref: 2024-0353

Deceased name: Raymond Watkins

Coroner name: Joanne Kearsley

Coroner Area: Manchester North

Category: Hospital Death (Clinical Procedures and medical management) related deaths

This report is being sent to: Department of Health and Social Care

1. Rt Hon Victoria Atkins, Department of Health And Social Care, 39 Victoria Street, London, SW1H 0EU
I am Joanne Kearsley, Senior Coroner for the Coroner area of Manchester North
I make this report under paragraph 7, Schedule 5, of the Coroner’s and Justice Act 2009 and Regulations 28 and 29 of the Coroners (Investigations) Regulations 2013
On the 21st December 2022, I commenced an investigation into the death of Raymond Horace Watkins. Raymond Watkins died on the 28th November 2022 at Royal Oldham hospital. The investigation concluded on the 26th June 2024.

The medical cause of death was confirmed as 1a) Septicaemia 1b) Insulin controlled Type 2 Diabetes, Chronic Obstructive Pulmonary Disease, lschaemic Heart Disease, Pressure Ulcers 2) Cerebrovascular Accident
Mr Watkins had been admitted to hospital on the 4th November 2022. During this admission he was placed on end of life palliative care and his usual medications including his insulin were stopped. He was discharged from hospital on the 10th November 2022 to his care home. The following day Mr Watkins advised the home, his GP and others that he wanted to restart his medications including his insulin. At this stage Mr Watkins had capacity and his clinical picture had improved. The GP prescribed his insulin and the authorisation required by the District Nurses for them to administer the same. The court heard that an authorisation is required before District Nurses can administer the same. Due to administrative errors both within the GP practice and the District Nurse practice this prescription was not authorised before Mr Watkins was readmitted to hospital on the 22nd November 2022. An initial forensic post mortem had considered the medical cause of death to be directly attributable to the lack of insulin however further expert evidence concluded that the prescribing of further insulin would, in this case not have been appropriate and in any event would not have made any difference. The cause of death was therefore revised. However it was acknowledged by all Interested Persons and the expert that the breakdown in communication between the GP and District Nurses was indefensible and could in a different case have been causative.    

As a result of their investigation into this case the Northern Care Alliance has developed and rolled out across 4 areas of Greater Manchester a “Time Critical Medicine” process for District Nurses advising them as to which medicines are considered time critical and what steps to take if authorisations are not correctly completed on receipt.

This includes:  
Contacting the Prescriber and immediately raising a datix incident
Returning to the prescriber within 2 hours if correct authorisation is not received
Escalation by end of shift to a manager
Escalation following morning to the Assistant Director of Nursing
The implementation of this Standard Operating Procedure which came into place in March 2024, led to the number of datix incidents increasing significantly, highlighting the widespread issue. However since its implementation this has raised the awareness amongst GPs and prescribers of errors and the numbers have declined dramatically to the point where practices are making real differences to the ability for patients to access such medicines.
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:
1. During the course of the evidence the court heard that receipt of correct authorisations in respect of medicines is an issue faced by District Nurses in many areas of the country.
Currently there is no ‘Time Critical Medicine” guidance for the community setting.
In my opinion action should be taken to prevent future deaths and I believe each of you respectively 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 21 August 2024. 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.
I have sent a copy of my report to the Chief Coroner and to the following Interested Persons namely:-
Family of Mr Watkins
Northern Care Alliance
Abbeycare Care Home
The Alexandra Group Medical Practice
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 from. 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.