Dear Mr Gittins,

REGULATION 28 REPORT TO PREVENT FUTURE DEATHS Margaret Joy Daly

I write in response to the Regulation 28 Report to Prevent Future Deaths dated 28 October 2024, issued by yourself to Betsi Cadwaladr University Health Board, following the inquest touching upon the death of Mrs Margaret Daly.

I would like to begin by offering my deepest condolences to the family and friends of Mrs Daly.

In the notice, you highlighted your concerns that the clinician who prescribed a sedative did so without reference to any of Mrs Daly’s notes other than her prescription chart, and that as a result they were unaware of her enhanced falls risk or any other behavioural issues.

In response to the notice, I requested our East team Medical Director, Nursing Director and Pharmacy Director to consider your concerns and provide details of their plans to make our services as safe as possible, taking into account the learning from the inquest.

Having considered the learning, a new process is being established by the East Medical Director to improve safety whilst recognising medication changes may be necessary without the doctor being able to review a patient in person.

Doctors will be told to only prescribe without reviewing the patient in person if they have the notes brought to them, and nursing staff will be told they must relay the falls risk to the doctor at the time of discussing or escalating the patient. If the doctor has any doubts about safe prescribing then they will be told to attend the patient at their earliest opportunity and assess, or they should escalate to another doctor if they can’t get there quickly.

The learning and actions from our East team will also be shared with our teams in central and west for wider learning.

Ein cyf / Our ref: Eichcyf / Your ref: : Gofynnwch am / Ask for: E-bost / Email: Dyddiad / Date: 20 December 2024 John Gittins HM Senior Coroner North Wales (East and Central) Coroner's Office County Hall Wynnstay Road Ruthin LL15 1YN Bloc 5, Llys Carlton, Parc BusnesLlanelwy, Llanelwy, LL17 0JG
---------------------------------- Block 5, Carlton Court, St Asaph Business Park, St Asaph, LL17 0JG

The longer term, and more sustainable solution is the development of an integrated electronic health record and I know our Chief Executive has discussed these developments with you.

In summary, the Health Board is progressing plans and business cases regarding an integrated electronic health record system.

The Health Board has now received formal confirmation from Welsh Government of the support for a Mental Health Electronic Health Record System, marking a significant step forward in relation to improving patient safety and experience, and the staff experience of coordinating and providing care. The Health Board will work closely with Cwm Taf Morgannwg University Health Board on this development as early implementers.

The wider Electronic Health Record Programme, which will go beyond mental health, is now established. The Strategic Outline Case was approved by the Board earlier this year and submitted to Welsh Government officials. One meeting has been held and a subsequent meeting is being arranged.

Whilst these solutions are longer term, they represent a significant endeavour with the Health Board taking a key and leading role in working with other organisations across Wales in developing the approach to such a major development.

The Health Board is also working to roll out an Electronic Prescribing and Medication Administration System (ePMA).

ePMA will replace the current paper based prescribing system across most specialties in acute and community services. Doctors, nurses, pharmacists and anyone who prescribes or works with medication will be trained to use the new system, which will run on laptops and tablets located in wards and other key areas. ePMA will streamline the process and make sure staff have access to a range of key information they need in one place.

This is the Health Board’s largest-ever transformation project and we are committed to making it a success. We have taken a user-centred approach with a dedicated multi- disciplinary team of nurses, pharmacists, doctors, and IT professionals, plus Clinical Champions and expert trainers to ensure ePMA works effectively. We aim for the pilot sites to go-live in March 2025.

I hope this letter sets out for you the actions that we are taking to address the concerns you raised.

I would be happy to meet with you and discuss our work to improve patient safety in more detail, or provide further information and assurance should that be helpful.

Once again, I offer my deepest condolences to the family and friends of Mrs Daly for their loss.