Janice Mary Davies · Prevention of Future Deaths report

I commenced an investigation on the 31st October 2018 into the death of Janice Mary Davies. Investigation concluded at the end of the inquest on 14th December 2018. The conclusion was Drug Related (prescription) Accidental death and the medical cause of death was 1a. Morphine Toxicity and Bilateral Rib Fractures 1b. Mechanical Fall 2. Chronic Obstructive Pulmonary Disease and Chronic Kidney Disease

On 19.4.18 Janice Davies fell out of bed at home sustaining fractured ribs. She attended the Royal Glamorgan Hospital that day, given 2 x 5ml doses of oramorph, prescribed 4 x 10mls oramorph daily - a supply of around 2 weeks and then, discharged home. She was unable to tolerate the oramorph after around lunchtime on 20.4.18 and following medical advice for her GP, switched to her usual pain killing medication - co-codamol and oxyNorm. Sometime thereafter, the concentration of morphine in her blood reached a toxic level, likely contributed to by her undiagnosed chronic kidney disease (discovered at post mortem examination). This has likely caused respiratory depression, which, on the background of impaired lung function has led to her death at home at ████████ in the early hours of 21.4.18.

In broad terms, the Inquest focused upon:-

a. The appropriateness of the care provided to the deceased at Royal Glamorgan Hospital on 19.4.18 & from her GP on 20.4.18
b. The dosages of oramorph given & prescribed to the deceased at Royal Glamorgan Hospital.
c. The observations of the deceased on 19.4.18
d. The discharging of the deceased on 19.4.18
e. The content of the advice (by telephone) given by her GP on 20.4.18 regarding her toleration of oramorph
f. The causal effects of the dosages of oramorph in the setting of the posthumously identified chronic kidney disease

(1) There was an absence of documented (despite indicated) observations of the deceased post her doses of oramorph at around 13:55 hrs & 15.40 hrs on 19.4.18.

(2) There was an absence of an updated & documented pain score prior to discharge. Most significantly, this, on the evidence of ████████ would have been desirable/required to inform the prescribing clinician, ████████ of the most appropriate prescription of oramorph to be given to the deceased upon discharge.

(3) Most significantly, there appeared, on the evidence, to be an absence of formal guidance or instruction-- written or otherwise to clinicians in the Accident & Emergency Department regarding the prescribing of oramorph to discharging patients. This would appear then to give rise to potential inconsistencies in the prescribing of oramorph to discharging patients. Not only in terms of prescribed dosages, but also in respect of the extent of the supply. The deceased was prescribed 40 mls per day & given a supply lasting two weeks. ████████ evidence was that in the absence of clear evidence as to the deceased's tolerance to morphine, he would be uncomfortable with this dosage & supply. His evidence was that a prescription of 20 mls per day, & a supply for 5 days (then review by GP if symptoms persisted/to assess the patient's reaction to the oramorph) was more appropriate in the circumstances.