Dear Ms. Mutch

Re: Regulation 28 Report to Prevent Future Deaths - Paul Michael Clark

Thank you for your Regulation 28 Report dated 16 October 2024 regarding the sad death of Paul Michael Clark. On behalf of NHS Greater Manchester Integrated Care (NHS GM), We would like to begin by offering our sincere condolences to Mr. Clark’s family for their loss.

Thank you for highlighting your concerns during the inquest which concluded on the 8 October 2024. On behalf of NHS GM, we apologise that you have had to bring these matters of concern to our attention. We recognise it is very important to ensure we make the necessary improvements to the quality and safety of future services.

During the inquest you identified the following cause for concern: -

The Inquest heard evidence that Paul Clark had previously been addicted to heroin. He had been successful in treating his opioid addiction and had remained opioid free for many years. His previous problems with opioids and the risk of opioids for him were well documented within his medical notes. However, despite the risks opioid painkillers presented to him, he had been started in primary care them at increasing levels, topping them up with non-prescribed opioids. There was no evidence before the inquest that the inherent risks of reintroducing opioids to someone who had previously been addicted to them were considered or monitored.

It was accepted in evidence that whilst opioid pain killers can be helpful for treating some patients, the risks of treating a patient with a former opioid addiction with opioids were significant and that there needed to be a very thought out rationale with careful monitoring to avoid increasing the chances of a patient relapsing into addiction through GP prescribed medication and that it was essential that GPs considered this when prescribing. Private & Confidential

Ms Alison Mutch H M Senior Coroner 1 Mount Tabor Street Stockport SK1 3XE

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4th Floor, Piccadilly Place, Manchester M1 3BN Tel: 0161 6257791 www.gmintegratedcare.org.uk The Electronic Medical Information System (EMIS) clinical system is a digital platform designed to manage and store patient health information electronically, facilitating improved healthcare delivery and record- keeping. This system enhances the efficiency of medical practices and allows for better patient care through easy access to medical records and data sharing among healthcare providers.

EMIS enables GPs to input a pop-up message / warning to alert clinicians to important information about an individual patient. Once an alert is set up, the message appears immediately that the patient record is accessed. Following the inquest, I can confirm that Archwood Medical Practice have undertaken an audit of their patient records to identify all patients with a history of drug addiction. A ‘pop up’ alert will be added to each identified record to ensure that anyone consulting with a patient within this cohort is immediately aware of the history and can therefore consider this history within their clinical decision making.

I can confirm that all GPs within Greater Manchester have access to guidance in the prescribing of opioid medications; this can be accessed via the following link:

web.pdfecific

In addition further national guidance is available via the National Institute for Health and Care Excellence:

In order to support our wider GP population, a Masterclass presentation on the subject of opioid prescribing was delivered to Stockport GPs and clinicians on 12 September 2024. The session title was ‘Pain Transformation, IMPS and Opioid Stewardship’. A total of 62 clinicians attended the session which was delivered by Dr Thomas Walton, Consultant in Anaesthesia and Pain Management.

The Regulation 28 report and our response will also be shared, in January 2025, for system learning with the GM cross-sector medicines safety group - the IPMO Medicines Safety Group. This group reports to the Greater Manchester Medicines Management Group (GMMG) and is co-chaired by NHS GM and Manchester University NHS Foundation Trust (MFT). The intention is to reflect on any learning from the Regulation 28 report and create a 7-minute briefing to be produced, disseminated to clinical staff and used for shared learning.

I hope the above information is helpful to you but if you do require any additional information, please do come back to me.

Best wishes

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Dear HM Coroner Alison Mutch

Regulation 28 Report to Prevent Future Deaths - touching on the death of Paul Michael Clark

Thank you for sharing a copy of your report touching on the tragic death of Mr Clark. I am responding on behalf of the Royal College of General Practitioners as Honorary Secretary to Council. Firstly, can I convey our sincere condolences to the family and friends of Paul, I was deeply saddened to read of the circumstances around his death.

The Royal College of General Practitioners (RCGP) is the largest membership organisation in the United Kingdom solely for GPs. It aims to encourage and maintain the highest standards of general medical practice and to act as the ‘voice’ of GPs on issues concerned with education; training; research; and clinical standards. Founded in 1952, the RCGP has just over 54,000 members who are committed to improving patient care, developing their own skills and promoting general practice as a discipline.

We have considered your report and offer our response focusing on the areas where the RCGP might have most significant influence to prevent further deaths. This includes supporting the understanding of managing addictions in General Practice as well as safety and quality processes in the prescribing of medicines. We would like to outline our response to your four matters of concern in these two areas.
1) Education (Curriculum and Continuing Professional Development)
2) Clinical Policy (Repeat Prescribing Toolkit)

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Education and Continuing Professional Development

The College is committed to upholding the highest professional standards and supports its members in the curriculum for new GPs in training, ongoing education and professional development. We hold national conferences and events reaching our membership and bringing the latest evidence and practice to support members as well as publishing a wide range of materials on our online platform which includes webinars interactive online resources and meetings. These materials include activity relevant to both ‘Managing Addiction’ as well as ‘Safe and effective prescribing’.

Curriculum

The College has a role in setting the Curriculum for General Practice which used to set the standards for training and is approved by the GMC. The core curriculum topic guide is wide ranging and includes a section on Smoking Alcohol and Substance misuse (p271).

Continuing Professional Development

The College supports all our members to keep up to date and regularly publishes Essential Knowledge updates (EKU) to reach all our GPs on a variety of clinical topic areas. These updates are regularly reviewed and updated by our CPD team. We have published two recent EKUs
2017.1 (reviewed in 2023) containing a section on ‘Treatment and management of opioid use disorder’ and 2022.3 in March 2023 which included an ‘Update on medicine dependence or withdrawal symptoms and opioid reduction’. These are widely used and evidenced as part of ongoing professional development by GP members.

We also provide the forum for GPs who have a particular interest and wish to gain a deeper understanding of the most current evidence, research and practice through Conference activity.

The College is holding a National Conference ‘Managing addictions in Primary care’ in conjunction with AP (Addiction Professionals) in Manchester on Thursday 16th and Friday 17th January in Manchester. This is an annual conference in its 29th year and part of our continued commitment to this clinical area and brings expertise from across the country with the specific Learning objectives to:

• Increase understanding of current interventions for the prevention, assessment and treatment of alcohol and other drug problems
• Increase understanding of what interventions are possible to deliver in primary care and what require specialist help
• Increase knowledge of drug and alcohol policies in the UK and how they are implemented in primary care
• Increase knowledge of links between multiple needs, health inequalities and drug and alcohol use

Clinical Policy We have recognised the importance of safety in repeat prescribing and the role that General Practice and Community Pharmacy have in this space. Through our Clinical Policy work we have A4

collaborated with the Royal Pharmaceutical Society and over the last year, I co-chaired a group to develop a New Repeat Prescribing Toolkit to improve safety and efficiency of repeat prescribing systems in general practices across England (the first of its kind in over 20 yrs). We launched this toolkit at our Annual Conference last month October 2024 in Liverpool and it has been circulated widely in open source (available members and non-members of RCGP and RPS). We recognise that safe and appropriate prescribing is a key skill for General Practitioners and something as a College that we take seriously. The new toolkit aims to support GP practice teams and primary care networks, working with community pharmacies and patients, to create a collaborative, safe and efficient process for repeat prescribing with the aim of improving practice processes, patient care and reducing waste. The toolkit also includes practical guidance on improving communication with patients about repeat prescribing, supported by good practice case studies, flow charts, action plan templates, and other useful resources. We have specifically highlighted the patient safety concerns around opioid prescribing within the toolkit, referencing a case example from a previous Regulation 28 Prevention of Future Death report in 2018. We hope that the toolkit shall be widely adopted and used by both GPs and Pharmacists working across England and beyond.

We shall remain committed to this important area in prescribing and the support for members to maintain high standards but recognise that in this case these standards were not met, and our sincere condolences go to his family.