Jonathan Paul SZCZEPANSKI · Prevention of Future Deaths report

On 31 May 2023 I commenced an investigation into the death of Jonathan Paul SZCZEPANSKI aged 64.

The investigation concluded at the end of the inquest on Monday 13 May 2024. The conclusion of the inquest was:

Medical cause of death:
1(a) Upper Gastrointestinal Haemorrhage
1(b) Duodenal Ulcer
2 Naproxen Treatment

Conclusion
Mr Jonathan Paul Szczepanski died from the consequence of a duodenal ulcer to which the prescription of Naproxen without the corresponding Proton Pump Inhibitor (PPI) made a contribution.

(1) Mr Jonathan Paul Szczepanski had a significant medical history which included
Parkinson's Disease, Type 2 Diabetes, Hypertension and Spinal Stenosis.
(2) He had several repeat prescriptions from his GP surgery to treat his conditions and
to provide pain relief. This included Naproxen, a non-steroid anti-inflammatory drug
(NSAID) which had been prescribed regularly since 2016 on a dosage level of
500mg twice daily.
(3) No corresponding proton pump inhibitor (PPI) medication had ever been prescribed
to address the recognised risk of duodenal ulceration from NSAIDs.
(4) No medication reviews had taken place to address or manage the risks of long term
NSAID prescription, against the background of his relevant co-morbidities.
(5) He was admitted to Boston Pilgrim Hospital on 28 April 2024 with an acute kidney
injury due to suspected infection and urinary retention. He was discharged on 2
May 2024 with a repeat prescription of Naproxen - 500mg twice daily. No PPI
medication was prescribed.
(6) He was admitted to Boston Hospital on 14 May 2023 with symptoms indicative of a
gastrointestinal bleed. Despite repeated medical and surgical intervention, he did
not respond to treatment and his condition was such that further intervention was
not possible.
(7) He was placed on end-of-life care until he passed away.

(1) There is a lack of local practitioner guidance on the practical implementation of the
NICE NSAIDs - prescribing issues documentation.
(2) The software being used to prescribe NSAIDs did not automatically generate a
specific warning flag to alert the prescriber to the considerations and risk factors in
the prescription of NSAIDs (including the use of PPI).
(3) Where repeat prescriptions were issued on discharge of a patient from hospital back
to community primary care, there was no warning on the discharge documentation
to alert the prescriber to the considerations and risk factors in the prescription of
NSAIDs (including the use of PPI).