Dear Mr Place

Avery Jake Hall: Prevention of Future Deaths Report

I am writing on behalf of the Riverview Surgery in response to your Prevention of Future Deaths Report (PFDR) dated 2 February 2026 in order to provide you with information regarding the further steps we are taking in addition to those set out in the SEA to ensure that there is no recurrence of these devastating events.

For completeness, I attach the SEA detailing the steps taken previously. Following receipt of your PFDR, I have considered carefully your concerns and conclusion and revisited the SEA in order to further develop the systems currently in place, to address your concerns. These additional changes are as follows:
1. An SOP has been implemented in relation to prescribing medication to women of child bearing age (15-55 years old). I attach the SOP. A clinical practice meeting has been arranged for 26 February 2026 at which the SOP will be discussed and laminated copies distributed.
2. The SOP goes further than the previous SEA in the following respects:

a. It relates to any new medication at the point of initiation.
b. If there is a concern as to a medication’s safety in pregnancy, the medication is to be stopped and removed from the repeat and acute list of medications and the patient advised of safe alternative medication.
3. As set out in the SEA, a review of all female patients of child bearing age who are prescribed ARB medication was to be undertaken every 6 months and an alert added to their prescription to stop taking this medication if they become pregnant and to speak to their GP. The frequency of this review has now been increased to 3-monthly in light of the risks of this medication in later pregnancy. In addition, as most prescriptions are now electronic rather than paper copies, the alert will be added to the prescribing instructions section so that it is clearly shown on the label printed for the patient’s medication by the pharmacy when they collect their medication.

I wish to make clear that had I known of the BNF warning for candesartan in 2024, I would have given definitive advice that it must be stopped and I would have removed it from the repeat prescription list. The SOP will ensure that patients receive an early alert and counselling in relation to any concerns about their current medications should they become pregnant. Once the patient informs the practice of their pregnancy, an urgent review will take place with a doctor to address their current medication risks, stop medications which are contraindicated or for which there is concern about their safety in pregnancy and advise upon safe alternatives. Had the SOP been in existence in April 2024, it would have led me to stop the 3 medications which the BNF advised avoiding or were contraindicated in pregnancy, namely candesartan, melatonin and lansoprazole, and to remove them from the acute and repeat prescription lists.

I have also considered further whether it is possible to identify or flag a pregnant patient when they request repeat medication. This would be an important safeguard for doctors reviewing the two hundred or so repeat medication requests received on a daily basis. Due to their volume and the other priorities for clinicians’ time, it is not practical for the doctor to review each patient’s records when authorising every request. We do not have the technical IT skills at the practice to make changes to the computerised records system and I have therefore contacted our system provider EMIS to ask for their advice and input on whether it is possible, and if so how, to introduce a flag which would identify the pregnancy coding on the patient’s record and link it to the repeat prescriptions for the patient (and ideally include the BNF advice for that medication as well). I hope that this is a proportionate and practical way to address the

issue you have raised, which will further strengthen the safeguards in place with the 3 monthly review of all female patients of child bearing age prescribed ARB medication.

I wish to make clear how seriously I and the practice take the issues you have raised and hope you are reassured by the steps already undertaken and the further steps which are being undertaken following your PFDR.

Dear Mr Place

Regulation 28 Report to Prevent Future Deaths - regarding the death of Master Avery Jake Hall

Thank you for asking us to comment on the matters of concern following the sad death of Avery Jake Hall who died on the 13th of November 2024.

Our sincere condolences go to his family given the difficult circumstances and the ongoing questions on how this could have been prevented. We will address the issues raised as requested in the hope that the response can help answer the concerns of the Coroner and Avery’s loved ones.

You have numerous matters of concern relating to this deeply upsetting death.

• Continuation of repeat prescribing of Candesartan throughout the pregnancy in spite of the GP’s clinical advice to stop the medication on 11th April 2024.

• The lack of specific advice regarding Candesartan in pregnancy and the risks involved.

• Missed opportunities to highlight the risks with clinicians through her multiple attendances through her antenatal care.

To give context to the family, The Royal College of General Practitioners works to improve patient care by encouraging the highest possible standards in general medical practice by supporting members, setting standards, providing education and training, promoting research and advocating and representing the College and its 56,000 members.

Training General Practitioners have a broad curriculum, and the College is responsible for the definitive educational framework for all doctors undertaking GP speciality training. Within GP

Training there is now a mandatory Prescribing Assessment, introduced in 2019, to examine prescribing decisions, assessing against current evidence, considering prescribing in special groups including children, the elderly or in pregnancy.

Within the RCGP Womens Health toolkit, the breadth of information resources on prescribing in pregnancy are provided with links, including the Specialist Pharmacy Service, (SPS) https://www.sps.nhs.uk/articles/the-risks-and-principles-of-prescribing-in-pregnancy/

Prescribing in Pregnancy is a specific section within the British National Formulary, (BNF), available online, listing specific concerns for each drug reflecting known evidence from trials and continuing monitoring. Clear advice is given as to whether the medication should be avoided, may have harmful effects or when it is not known to be harmful, with the current advice that Candesartan should be avoided.

Information resources are readily available to both clinicians via UKTIS and their patient- facing resource BUMPs (Best Use of Medicines in Pregnancy) websites, summarising the current known evidence for medications prescribed for pre-existing conditions prior to pregnancy, as in Candesartan for the indication of migraines. Full monographs are available to healthcare professionals when we register with the site using our nhs.net email address.

These pages are updated when new evidence evolves and from my own viewing the current information was last updated https://uktis.org/monographs/use-of-angiotensin-ii-receptor- antagonists-in-pregnancy/ in July 2025 and https://www.medicinesinpregnancy.org/leaflets- a-z/angiotensin-receptor-blockers/ January 2026 on UKTIS and BUMPs respectively.

A phone number allows healthcare professionals to contact UKTIS for help and advice if required: 0344 892 0909.

Systems GP Information Technology Systems give prescribing alerts at the point of issuing the prescription. There is no single GP IT System and each supplier will have their own prescribing advice software, for example EMIS, SystmOne and Medicus. Communication with these suppliers would be valuable to clarify a system-wide safety net in the event of human error leaving a harmful prescription within repeat medications for a patient coded as being pregnant.

The manufacturers DCB0129 hazard log will have a specific hazard identifying medication causing harm, one cause of which is a change in clinical circumstances rendering an existing repeat prescription unsafe. The hazard "controls" (things that reduce the risk) include presenting information to the users at the relevant moments e.g.

• When a new codable condition is added which can computably surface a warning,
• When a digital prescribing safety check is activated by a user,
• When a repeat prescription request is being reviewed prior to being issued,
• What systems are in place to identify and manage Alert Fatigue in users

Systems do seem to highlight the risks at the point of initiation as a new prescription. It is unclear whether an Alert is raised across all systems for existing repeat prescriptions, such as Candesartan in this case. Exploration of this issue with the suppliers would be valuable to avoid further events.

The next layer of safety in prescribing is the dispensing pharmacist, who may refer the prescription back to the prescriber if they identify a risk or concern. This area of the process is beyond the remit of the RCGP.

A development that has subsequently become available is the contractual obligation to report such incidents to the Learning From Patient Safety Exercise (LFPSE) established in October 2025, following on from the National Reporting and Learning System, which was utilised predominantly by secondary care health services.

Once again, our condolences go to Avery’s parents and family. I hope the comments provide a full picture of where the RCGP can influence the prevention of future deaths within training and continuing professional development.