Dear Mr Cohen

Re: Humankinds response in regard to the Regulation 28, following the Inquest into the late Dayle Bates

Following on from your letter dated 8th February 2024, which outlined the matters of concern identified during the coronial process, as the Area Manager of the addictions services within Cumbria I would like to detail a response to the particular concerns you have raised.

It is stated within your findings that Recovery Steps Cumbria issued Mr Bates with a methadone prescription, to clarify Mr Bates’ care was managed under Shared Care, which means that he was provided with Opioid Substitute Treatment (OST) via his General Practitioner, with Recovery Steps Cumbria working in partnership with the GP to deliver psychosocial interventions. In this instance the prescriber was from James St Surgery in Workington, and it is the GP surgery who owns the prescription and is responsible for the management of medication in Mr Bates’ case.

With regards to the comments made by the Community Pharmacy, they are inaccurate. There is a duty upon Pharmacists with regards to liaison with prescribers for controlled medication as set out in their Medicines, Ethics and Practice Guidance (MEP). The actual wording from the MEP Guidance is: “If you know a patient has missed three days’ prescribed treatment (or the number of days defined by any local agreement with the prescriber), there is a risk that they will have lost tolerance to the drug and the usual dose may cause overdose. In the best interests of the patient, consider contacting the prescriber to discuss appropriate next steps.” MEP Section 3.6.7 Prescription requirements for Schedule 2 and 3 Controlled Drugs.

Recovery Steps Cumbria is a service led by Humankind. Humankind is a company registered in England. Registered Company No1820492 and a Registered Charity No. 515755. VAT No 334676343.Registered Social Landlord (RSL) 4713Registered Office: Inspiration House, Unit 22 Bowburn North Industrial Estate DH6 5PF

Although in this instance the prescription wasn’t managed by Recovery Steps Cumbria, as a point of further assurance in regard to how Humankind manages communication with Community Pharmacies, all prescriptions generated by Recovery Steps Cumbria has official Home Office approved wording on them which states "Please dispense instalments due on pharmacy closed days on a prior suitable day. If a collection has been missed, please dispense the amount due for remaining day(s). Consult a prescriber if 3 or more consecutive days have been missed. Dispense daily doses in separate containers”.

As of January 2024, The Office for Health Improvement and Disparities has published new guidance for Community Pharmacies delivering substance misuse services, under the management of missed doses section, guidance clearly states “If a person misses 3 consecutive doses (or any doses during titration) for an opioid substitute, the pharmacist should put the prescription ‘on hold’. The pharmacist (or another designated pharmacy staff member) should then contact the prescriber to discuss if it’s suitable to continue to supply the opioid substitute. If they cannot contact the prescriber (for example when working out of hours), the person may be refused one or more doses. The pharmacist should record all refusals (with associated rationale) on the person’s PMR and on the prescription, and they should tell the prescriber as soon as possible”. While the publication date for this was after the date of this case, it is clear from the MEP guidance and “best practice” in supporting patients prescribed OST that pharmacists contact the prescriber i.e., the Shared Care GP, if a patient has failed to collect 3-days consecutive OST medication.

Humankind has Service Level Agreement’s (SLA’s) in place with Community Pharmacies who deliver Supervised Consumption and Needle and Syringe provision on behalf of the service. Humankind also has SLA’s in place with all GP surgeries who deliver Shared Care. In all SLA’s there is clear guidance with regards to the roles and responsibilities of each party. A copy of the current SLA for Community Pharmacies delivering OST supervised consumption services has been attached for your information. For point of clarity, Mr Bates was not on supervised consumption at the time of his death, however, it was felt appropriate to share the content of the SLA to demonstrate the duty placed on parties in regard to the appropriate management of cases, in particular those cases where consecutive missed doses occur.

In response to the concerns raised regarding the difficulty the Community Pharmacy experienced contacting the service, Humankind has completed an in-depth reviewal of the clinical system the service uses, to establish any recorded activity contained within Mr Bates case file or in reference to Mr Bates’s treatment during the time period when Mr Bates stopped collecting his medication until the time Recovery Steps Cumbria were notified of his death. No activity was found during this time period. In addition, phone data was requested from the telephone provider to enable call analysis to be conducted, however, only 6 months’ worth of historical data can be accessed which didn’t cover the time period being reviewed. Although Recovery Steps has found no evidence that a call was received, or that a named worker was contacted by the Community Pharmacy, the service has communicated with all staff the importance of accurate record keeping and information sharing following all phone calls received. This has also been included in Recovery Steps Cumbria’s record keeping training.

Recovery Steps Cumbria has 2 predominant contact methods that are used by partners and individuals seeking support, the first being via telephone, where one phone number is used

Recovery Steps Cumbria is a service led by Humankind. Humankind is a company registered in England. Registered Company No1820492 and a Registered Charity No. 515755. VAT No 334676343.Registered Social Landlord (RSL) 4713Registered Office: Inspiration House, Unit 22 Bowburn North Industrial Estate DH6 5PF

to cover all sites within Cumbria, we have a dedicated team of Administrators who answer all incoming calls during opening hours. Humankind does acknowledge that at times phone lines are busy, which can mean a delay in getting through to an Administrator. The second general contact method is via email, the service has a referral email address and an additional secure email address, which is predominantly used by partner agencies, both email accounts are monitored daily.

For assurance, in light of your findings, Humankind has undertaken a targeted piece of work to address and reduce risk in the hope that future deaths are prevented, this work includes:

• That all Community Pharmacies have correct contact information for Recovery Steps Cumbria, including phone numbers and secure email addresses.
• That all Community Pharmacies are aware of the obligations on them when it comes to dispensing Opioid Substitution Treatment.
• Communication has been had with both the North and South Cumbria Pharmaceutical Committees.
• That the medicines optimisation leads from both North and South Cumbria’s Integrated Care Boards are informed of the issue that has been highlighted and that there is a co-ordinated approach to services delivered to the people in Cumbria.
• Communication had with all Shared Care services, to ascertain if approved Home Office wording is detailed on all prescriptions generated, if not, for them to ensure it is added moving forward.

I hope that the above offers reassurance in respect of how Humankind has responded to the issues you have raised. Reducing drug and alcohol related deaths within the county is a priority for Humankind, and we are committed to working collaboratively with all partner agencies to learn from and reduce the number of deaths in the area.