Leonardus Adrianus VRIES · Prevention of Future Deaths report

On 10th October 2014 I commenced an investigation into the death of Leonardus Adrianus Gerardus VRIES then aged 48 years.

The investigation concluded at the end of the inquest on 4th March 2015.
The conclusion of the inquest was accidental death the medical cause of death being 1(a) respiratory depression, 1(b) combined toxicity of bupivacaine and morphine and diamorphine.

Mr Vries apparently acquired medical grade drugs from his place of work and used them to inject himself at his family home where he died.

(1) It appeared in the evidence given by ████████ that there were significant documentary failings in the control of medication at the Royal Orthopaedic Hospital. Specifically he said there was no audit or any paper trail of the use of non-controlled medication. With regard to controlled medication it was accepted that there were documentary deficiencies which meant it could not be precisely ascertained what controlled medication had been taken or used or administered to patients.

Whilst the control of controlled medications appears to have been addressed by way of training and increased scrutiny and audit procedures ████████ confirms that there is still no audit of non-controlled medication. Specifically he said that when stocks of non-controlled medication are delivered to wards and departments there is no check as to who uses the medication or for what purpose.

It appears to me therefore that there is a significant opportunity for the abuse or theft of non-controlled medication.

████████ told me that the hospital were acting in accordance with the Department of Health guidelines in the matter and that unless the Department of Health issued further guidelines there would be no change in this process.

I suggest that the Trust needs to consider putting in place its own audit guidelines to ensure that what ████████ described as a "hole" in control measures is addressed.
(2)
(3)