Philip Allen · Prevention of Future Deaths report

On 16 October 2012 I commenced an investigation into the death of Philip Allen. The investigation concluded at the end of the inquest on 20 October 2014. The conclusion of the inquest was that he died of natural causes. The medical cause of death was vascular dementia.

Philip Allen was diagnosed with vascular dementia in 2009. In September 2012 following a deterioration in his condition he was transferred from The Oaks Care Centre to QEH where he died.

Mr Allen was admitted to The Oaks on or around 6 June 2012. He was seen by ████████ at that time a partner at Eltham Palace Surgery, who prescribed Quetiapine in addition to the Risperidone that Mr Allen was already taking. On 20 June 2012 Mr Allen was seen (at ████████ by ████████ consultant in old age psychiatry at Oxleas NHS Trust. ████████ discontinued the Quetiapine and wrote to Eltham Palace Surgery accordingly. Despite this letter it appears that the Quetiapine continued to be prescribed to Mr Allen as a repeat prescription by Eltham Palace Surgery until September 2012.

In evidence at the inquest ████████ who has now retired from practice, stated that the matter had been investigated at Eltham Palace Surgery as an untoward incident but he was unable to give details of this investigation.

████████ as Mr Allen’s GP, sought specialist advice from ████████. Not only was this advice not followed but the Quetiapine, which ████████ had stopped, continued to be prescribed as a repeat prescription on several occasions.

The evidence at the inquest was that the further prescriptions of Quetiapine did not contribute to the death. However, I am concerned that the system at Eltham Palace Surgery did not prevent the repeat prescription. ████████ was unable to say if changes have been made since this incident.