Dear Assistant Coroner Re: Mrs Ruth Edwards DOB. 29/01/1953 52 Celtic Rhoose CF62 3FT Many thanks for the report and investigation into the circumstances surrounding the sad death of Mrs Edwards. have read the comments on the report and would entirely agree with those that have been pointed out: Specifically with relation to the comments regarding medication reviews with ourselves as General Practitioners, we would recognise that this presents particular challenge to us and safe prescribing of medicine requires great deal of resource_ In the last 12 months we have taken on Clinical Pharmacist within the Practice Team on a full time basis whose responsibility it has been to oversee and improve the governance regarding repeat prescribing and acute prescribing of medications plus patient monitoring: We have in fact achieved an NHS award for quality improvement in this area and although this may have come too late for Mrs Edwards in order to reduce her risk; would be confident that we have made great strides over and above that we would expect to meet standards of our General Practice. That said, we would also bring these comments to our monthly significant events meeting to highlight the importance of medication reviews and high risk patients to all of our clinical staff, Way Barry

hope this in someway can reassure the family that measures are being made and that Mrs Edwards will at least go someway to improving medication safety for other patients in the future_

Dear Miss Knight Ruth Ellen Edwards (deceased) D.O.D. 31/08/2018 Thank you for your letter of 20 December 2018, in which you outline your concems regarding the death of Mrs Ruth Edwards, and issue a Regulation 28 order detailing the areas you wish the University Health Board to consider: We recognise that this will have been a very difficult time for Mrs Edwards's family and would like t0 offer our most sincere condolences; The University Health Board has conducted an interal review of the processes (known as the Multi-Disciplinary Case Review or MCR) involved in the care and treatment offered to Mrs Edwards following her presentation at the University Hospital of Wales (Accident and Emergency). Unfortunately no member of UHB staff who were involved in dealing with Mrs Edwards were called to give evidence at the Inquest and it may have been possible to provide some further assurance in relation to the areas of concern that have been highlighted: Your concerns with regards to her care are as follows: That Mrs Edwards was discharged from hospital following an overdose on 23rd August to see GP was surprising: It was expected In these clrcumstances that Mrs Edwards would have been transferred to Llandough Hospltal for psychiatric Iiaison assessment Instead; responsibility for any further assessment and treatment of Mrs Edwards was passed entirely to Mrs Edwards and her famlly: A less capable familylindividual may not have pursued help and fallen through the cracks. Furthermore had Mrs Edwards been hospitalised, her treatment may have been different: Cvrdc Jechyu Prlfvsn0l Caurcrdd #r Fro Yw Crw Qweatiredal Bwirdd {echyd Ueal Priryspol Cacrdyd] 0r Fra Curdim era VJ? UJnversity Heskh Aojid Und @pw"arlanal ninid 0r Car ard Vile UnlverFil # Lccal Haailh Bqaru

concluded that the care and treatment giverREACS The findings of our interal MCR headthhassessment conducted by the REACT Edwards from the of the mental demonstrated full awareness of Mrs tecwathe following day; Was comprehensive and of her overdose the previous Eawards's history, her level of risk thettrue naturec family to provide safe this the capability of Mrs Edwards's and balanced and supportive context have been in UHB would absolutely concur that someuGaeiieent agt atshEdwards might position) to providepongoing supporen benttrouudgenene REfACT teamwvaras made poriabn at?home with regular and dregureerant Ofl nc@uding the team; the patient with the conscious participation and agreement of the family: by all professionals involved that considecation_ It is clear from the accounts given Mrs Edwards should be admitted to was given almost on daily basis to whether consciously balanced against the hospital bed. It is equally clear that this was detrimental to Mrs Edwards; Mrs possibility that hospital admissionhmay haogoiaeadreissiom It is normal and Edwsards herself was not amenable t0 hospitac wherever possible, and it was toeprovide treatment and support at home in this case , based on the that the decision to do this was appropriate concluded available to clinicians at the time. infomatlon that was was poor: The history taking was The consultation at the UHW on 23 August of Mrs Edwards risk In terms of inadequate as it did not reveal the trueeexteet mental health problems: prevlous suiclde attempts and deag coeareunicaeed to Iiaison psychiatry; Frevhermore, inaccurate Information was tablets when she had taken 20. told that Mrs Edwards had taken 2 they were with mental health services for many Mrs Edwards had not hadrany iniorenaeir aailableta theaassessing doctor from MearEaandrthere was therefore minforARIfomevzalahealth' tecord Beher paper notes Or the electriored FOARI inontatibnalha tecorEdwards and thosh Wvouid therefore have been restricted to thee Edwards's involvement with accompanging her) gave him at thevereveaad Mnen PARIS history would have aealtrg been within the last several years ther 0 patients presenting In mental and be available for other been available to) similar circumstances there was typographical error in the Our review has Identified that; although Sertraline had been taken when in fact docureentation stating that only two tabletsec the night In question: when) was twenty, this error was rectified 01 coordinator for mental the true figure with Mark Bates night site made had his discussion tablets had been taken and health services) both individuals knewi thatboretola the notes taken by teeir clinical decision on that basis This is borie itey coordinatorain mental health the time, and also can confimm that the night site in which he has written at heas ocatedo his own personal notes from thatogaol error was therefore services took twenty tablets, not two; The typographical = that Mrs Edwards making process on that night not a factor in the decision lechd Uecl Prityrac Caerdrod Fid Caerdydd ar Fro YM enw @warioneca EeyOCG Aer Wand Vae Urrveniy Local Heaih Baard en Icchyd Fotrysooi Baa f tne opefatinal nare Cijmt 43J VJ Jaruty Hetn point day against not and good practice system will (the

The GP practice may not have performed sultable frequent medicatlon reviews with Mrs Edwards. Many boxes of different tablets were found at the family home. Many on repeat prescrlption posing an overdose risk: This issue will be raised this with the Primary, Community and Intermediate Care Clinical Board as a practice issue for them t0 consider_ With regards to the speclfic Issues you have asked the UHB t0 consider in order to prevent future deaths: The Identification %f patients who requlre Immedlate psychiatric assessments and review by specialist teams. The UHB uses the Bristol Matrix, a decision making tool which is used t support the identification of patients who require psychiatric assessments. This decision making can also be conducted jointly with senior mental health staff. can confirm that training in the use of the Bristol Matrix is well established, that all junior doctors leam about it during their induction to the department and are familiar with its use whlch is standard practice in this kind of situation_ The doctor that conducted the initial assessment is a locum in the department but has many years' experience in emergency medicine and works regularly in the department; She has had training in the assessment of the patient with mental health problems and would have felt confident in entrusting a decision that the patient was low risk and safe for out- patient review: The care and attention to detail taken by doctors and other healthcare professionals when nothing histories and Information from mental health patients. Although the internal MCR has identified a typographical error as described above the general standard of documentation was found to be satisfactory: All staff will, however; be reminded of the Importance of full and diligent infomation taking, using all information that is available at the time and this will be achieved through the Clinical Board's Quality, Safety and Experience structures. The frequency of medication reviews with mental health patients Mrs Edwards was not known to secondary care mental health services at the time of her death: care was being provided by her General Practitioner. The management of patients with Depression is carried out in line with NICE Guidance 'CG9O Depression in adults: recognition and management' and there is a standard for the regular review of patients depending on the nature and severity of their depression: This matter has been raised with the Primary Community and Intermediate Care Clinical Board as a practice Issue for them t0 consider, Bwrd Hecnya Prrysca} Caerdyd 1 a r Fro Vw Ga Dwelthredc) Awxrdd Iechrd Ucol Prifyspci Caeruvdd #'r Fro Cirdim 4mU VJe Uz*cr1y 'Icjiin Bosra L70 cperad3aai njna ( Caed And Vale Ur ~Ffsty oCdi Helih Bowrd Her

hope that the Information set out in this letter provides you with the assurance that the Health Board has fully considered the issues raised as a consequence of inquest into Mrs Edwards's death, and has taken appropriate action in response: