Dear Miss Hamilton-Deeley The late loannis Avgousti Thank you for your letter of 24 April 2019 enclosing your report written under Paragraph 7 , Schedule 5 of the Coroner's & Justice Act 2009 and Regulations 28 and 29 of the Coroner's (investigations) Regulations 2013,and the Record of Inquest. note your conclusion that the reaction was not directly causative and was unlikely to have accelerated his death. would however like to send my sympathies to Mr Avgousti's family on behalf of the Trust and assure you and his family and friends that we have taken the learning from the inquest extremely seriously and my apologies and condolences go to his loving family and friends at this very difficult time_ This letter is intended to demonstrate the learning and improvements we have made, some prior to the inquest; and some post inquest; to make the Trust safer for our patients, staff and visitors Nice Guidance for the Diagnosis and Management of Allergy Head of Nursing for Quality Improvement has undertaken work in conjunction with Pharmacv team to ensure that the Trust is fully compliant with these NICE guidelines hhas confirmed that the Trust is currently compliant with most Of the guidelines and has produced an action plan for the remaining guidelines. This includes a tool; to describe reactions and to determine actual allergy status, which has been developed and this tool will be incorporated into the new design of the Trust's Prescription chart: The next print run of our newly designed Prescription charts will include: Medication Name Reaction Decision tool to determine whether the medication is safe to administer to patient concerned. We have redesigned our prescription charts. The Medication status box has been moved to a new position on our new prescription charts so that it is continually visible to Hove the the allergy

W Brighton and Sussex University Hospitals NHS Trust prescribers and not obscured when the page is turned. The new charts are being printed and will be launched before the new intake of junior doctors_ All of the above will be incorporated into the EPMA (Electronic Prescribing and Medicines Administration) system; The business case for this package has been approved and the specification is currently being finalised. We are waiting for an imminent NHS England allocation of funding decision in order to purchase the EPMA package. Once commenced we our aim is for 80% of wards to have EPMA within 2 years. The Chief of Pharmacy and his team are leading on this work We have established a Penicillin sub-group of the Medicines Governance Group to keep the messages from Mr Avgousti's inquest priority in the minds of all our staff Medicines reconciliation is now undertaken for every patient as soon as possible after they have been admitted to hospital. In relation to the non adherence to Trust policy, three Safety Alerts have been sent electronically to all staff to highlight the importance of Medicines Management and Safety. These include 'Medicines Safety' being a theme of month; teams discuss theme of the month at their daily safety huddles to keep the message fresh and to reach staff who may not have ready access to their emails_ The ward nurses have also received refresher training and senior assessment on intravenous medication administration, this has been confirmed by the Ward Manager of Vallance ward. We have undertaken extensive investigation into the use of red allergy wrist bands; led by the Head of Nursing Quality Improvement We have conducted three audits of the appropriate use of red wristbands since January 2019 and there has been 10% improvement on compliance In addition, our Acute Admissions Unit and Emergency Department are trialing a single coloured wristband system whereby if a patient has an allergy, will only wear a red wristband with their details on it, and not an additional white wristband_ The aim of this trial is to see if it reduces the risk of the red wristband not seen when checking patients' details prior to medication administration and our patients like Mr Avgousti who gather did not like wearing multiple wristbands and would sometimes them off;, more comfortable and reducing the risk of removal. To supplement this trial the Acute Admissions Unit team have place bespoke training programme for staff in order to highlight the risk of penicillin and the use of cO-amoxiclav. am delighted to say that over the last month there have been no penicillin related incidents on the Acute Floor at the Royal Sussex County Hospital: These improvements will then be extended to other areas of the Trust: NEWS agree with you that NEWS is a very important tool and should be used and followed correctly. regret the NEWS documentation was not to the standard we expect. The ward team have reflected at length and the case was discussed by the wider team at Medicine Division's Clinical Governance meeting on 17
2019. am pleased to say, after a successful trial, the Trust has purchased an electronic system for recording NEWS and nursing assessments_ This system is currently rolling out electronic recording of observations, the NEWS scores of all patients will therefore be available to view by the Allergy top the the they being pull being put allergy the May

WHS Brighton and Sussex University Hospitals NHS Trust Critical Care Outreach service, of which we are expanding, so escalation will be immediate rather than reliant on staff on the ward calculating the scores and putting out a MET call. Staffing As confirmed at the inquest, there is a new Trust Guardian for Safe Working in post and there has been a review of current best practice for preventing fatigue and ensuring optimal performance of junior doctors to make sure we are in line with our peer organisations and are providing support and sufficient rest for our staff. Again would like to extend my condolences and apologies to Mr Avgousti's family and friends. hope have been able to effectively demonstrate the work we have undertaken to improve the systems and processes in place. We strive to continuously learn and improve and feel sure that the learning from Mr Avgousti's inquest has improved the systems in place_ Finally, will ask Head of Medico-legal Services, to a copy of our new prescription chart trgiveyod when they have been printed.