Dear Mr Oliver, RESPONSE TO CORONER'S REGULATION 28 ORDER I am writing to provide a response to the Coroner's Regulation 28 Order issued in connection with the recent case of Mr John Hoare, deceased. We acknowledge and appreciate the importance of your inquiry and are committed to cooperating fully. Compliance with the Order: We want to assure you that Low Moor Medical Practice is fully committed to complying with the Coroner's Regulation 28 Order. We understand the significance of the information requested and the implications it holds for the prevention of future deaths. We have carried out internal review to gather all relevant information pertaining to the incident in question. As explained in my witness statement, we carried out our first meeting about our failure to issue Lithium medication on the 5th of March 2020, the day before Mr Hoare required detention under the mental health act. This indicates that we recognised the severity of the failure to issue lithium medication. We realised that we needed to revise our practice. As Lithium is a shared cared drug, indicating that it is a drug with increased risk associated with it, the joint action of both secondary care and primary care is required for its appropriate and safe administration. The supervision of such shared care drugs falls outside the standard GMS contract and is covered by separate guidelines, which can be found here. Shared care guidelines - South West Yorkshire Area Prescribing Committee (SWYAPC)South West Yorkshire Area Prescribing Committee (SWYAPC). We are actively collaborating with South West Yorkshire Area Prescribing committee, Bradford District Care Trust and Bradford District and Craven Health and Care Partnership, who have taken on board the concerns with regard to Lithium prescribing in general and specifically in regard to patients transferring between different care providers. The new guidance for prescribing Lithium is to be found here. Final_-Lithium-amber­ guidance-approved-23_03_2023-1-1.pdf (swyapc.org) and is also attached to this response. This issue took place involving a “Shared care Drug” prescribed to a patient in an “Intermediate care Unit”. Both Shared care Drugs and Intermediate Care units our outside Core General Practice and are covered by Local Enhance Services. The Shared care medication LES covers care in General Practice of patients while they are stable on medication. This patient had been discharged from hospital after admission with Lithium toxicity – by definition – not stable.

We do however accept that mistakes were made in the practice, and I have listed below measures we have put in place aimed at preventing future recurrence. Norman lodge - Change to Temporary Registration. We have made the significant change that patients admitted to Norman Lodge will only be registered as Temporary Residents. This keeps their home practice “in the loop”. We made this change 1/11/23. The original request for medication went from the care home to the original practice who did not prescribe because the patient was no longer registered with them. This is because our previous practice was to fully register patients in Norman Lodge. This is a significant improvement in continuity of care, enabling patients to remain with a practice that is familiar with the needs of these often complex patients. Pick up shared care in New Patients. We had processes in place to deal with prescribing reviews for new patients joining the practice, existing patients on shared care drugs, and prioritising new admissions to the intermediate care unit. Unfortunately, this case involved a combination of all three of these and there was a breakdown in the process. This was exacerbated by a hiatus in mental health care coordinator provision (nb a different role form the care coordinators mentioned below) as Mr Hoare’s previous care coordinator left in December 2019 and he was not seen by his new coordinator until March 2020, by which time his mental health had already deteriorated gravely. Medications to always issue. The Clinical Pharmacists are now aware of which medications (including shared care medications) need to be issued without interruption. In this case they were waiting for a Lithium level before issuing but this should not have happened. Community Advanced Nurse Practitioner for care Home. Since August 2023 we have employed a full time experienced ANP (16 years as a community Matron). Previously we had someone in post only 2 days a week. This has allowed greater oversight of these patients in the Intermediate Care beds. We are also discussing with the local Consultant Geriatrician about involving their team directly as many of these patients have been discharged from their hospital units to these beds. Lithium results. I am in discussion with our local Pathology laboratory about ensuring that Lithium results come to us as an individual result and not buried in a long list of Biochemistry results. This should reduce the risk of any Lithium result being overlooked. Ongoing care of patients on shared care drugs. I have started a discussion with , Medical director of Bradford district care trust, regarding the practice of discharging some patients on shared care medication from the mental health team, so that they are under the sole care of the primary care team (General Practice). Whilst not directly applicable in Mr Hoare’s case, this practice leads to increased risk in a vulnerable group of patients, and we are aiming to ensure that this practice does not continue.

Distribution of learning points and actions. Our senior partner, is on the Local Medical committee and is ensuring that the findings of Mr Hoare’s inquest are known to other practices within the Bradford District and Craven health care partnership. This document will be discussed at our regular practice meeting in order to ensure that appropriate clinicians are familiar with the shortcomings that occurred in this case and the actions taken above. The practice will ensure that these changes are audited on an annual basis, so that these measures can be reviewed and modified appropriately. I trust that this document will be accepted as a reasonable response to your Regulation 28 order. If you need further information, please do not hesitate to contact me at the practice.