Dear Mr Howe

Joshua BURGESS Executive Suite Trust Headquarters Springfield City General Site Newcastle Road Stoke on Trent ST4 6QG

Further to your letter 13 February 2024, I am pleased to provide a response under paragraph 7 of Schedule 5 of the Coroners and Justice Act 2009 and Regulations 28 and 29 of the coroner’s (Investigations) Regulations 2013, addressing your concerns surrounding the death of Joshua Burgess.

This response is provided on behalf of Brooke Medical Centre and the University Hospitals of North Midlands NHS Trust.

Concerns During the course of the inquest, you felt that evidence revealed matters giving rise for concern. In your opinion, matters for concern are as follows:

1. The Neurology department of the Royal Stoke University Hospital operated a system whereby it did not instruct the prescribing GP to amend the prescription of Brivaracetam when changes to dosage had been agreed with Mr Burgess’ mother. The evidence from the Consultant Neurologist was that an assumption was made that when changes to medication had been discussed and agreed that Mr Burgess’ mother would attend the GP surgery to discuss the changes in medication. The same witness gave evidence that it was assumed a pharmacist within the GP surgery would read the correspondence from the neurology department and make the necessary changes to prescriptions without express instructions to do so.

2. The ‘workflow’ within the Brook Medical Centre was such that letters sent from the Neurology Department discussing changes in medication (albeit not containing a request to amend the prescription) were processed by support staff and not referred to a clinician to consider and so no changes were made to the prescription.

3. The letter of 27 July 2022 from the Neurology Department to Brook Medical Centre seeking clarification as to the correct dosage of Brivaracetam was processed by support staff and a summary medication sent without referral to a clinician.

4. Godfrey Care were informed by Mr Burgess’ mother and the Neurology Department of Royal Stoke University Hospital that the appropriate dose of Brivaracetam was 4ml twice daily. Medication was withheld between 22-26 July 2022 due to the information not being in writing from the prescriber, however the evidence at inquest was that 10ml twice daily was commenced on 26 July following a call to the 111 service.

You reported this matter under Paragraph 7, Schedule 5 of the Coroners and Justice Act 2009 and Regulations 28 and 29 of the coroners (Investigations) Regulations 2013. In your opinion, action should be taken to prevent future deaths.

Action Taken The University Hospitals of North Midlands NHS Trust has taken the issues highlighted during the inquest seriously and indeed, I am grateful that you have raised your concerns.

We have taken this opportunity to work together with our partners in primary care and have consulted with colleagues from the wider the Integrated Care System (ICS).

1. The Trust’s outpatient clinic letter standards describe the structure of clinic letters based on standard headings. You will recall that (GP) gave evidence at the inquest to the effect that there were areas in the acute Trust setting which already provided discharge information which he considered to be of a ‘gold standard.’ The Trust is committed to working towards improving compliance with these standards. To support this, we are working towards creation of a standardised template in our ‘Medisec’ system (system where letters are created). This will include a section for changes to medications and clear actions for those in the primary care setting, for example, instructions for the prescribing GP to amend prescriptions.

2. We have discussed the above process with nominated individuals from the ICS. Due to the timeframes that would be required for the creation of standardised template for clinic letters within the ‘Medisec’ system across the Trust, we are reiterating the Trust standards and has agreed, with immediate effect, that all clinic letters received from neurology will be reviewed by a GP at Brook Medical Centre. This has been implemented due to the acknowledgement that neurological conditions are often complex, and it is more likely that they will require frequent medication changes, titration and/or closer monitoring.

3. This concern will also be addressed by the interim solution implemented by Brook Medical Centre, in that all correspondence from the neurology department will be reviewed and triaged by a GP.

4. Whilst this concern is not directly addressed to the acute Trust (UHNM) or Brook medical Centre, it has been considered as part of the wider learning following Joshua’s death. Medications for epilepsy is considered across the healthcare economy to be ‘critical’. The National Patient Safety Agency (2010) defined critical medicines as ‘medicines which can result in patient death or serious harm if

there are delays in their administration’. Whist the Coroner found that the delay in administering medications on this occasion did not contribute to Joshua’s death, we believe that further education within the care home setting is required. With this in mind, we will work together with the local authority to ensure that up to date communications are shared across the Stoke on Trent and North Staffordshire health and social care economy to reiterate this message. Whilst this has not yet been implemented, it will be taken forward by end of May 2024.

Whilst some changes have been implemented with immediate effect, other planned changes may take longer. However, we are committed to ensuring that correspondence between service providers is provided in an accurate and consistent manner.

We do hope that the above information provides assurance that the Trust and Brook Medical Centre have taken the concerns raised at the inquest seriously and that we are working together to ensure that communication of medication changes is clear and unambiguous between partners across the Staffordshire and Stoke on Trent health economy.

Should you wish to discuss any aspect of this report further, please do not hesitate to contact us directly.

Prevention of Future Deaths Report (Regulation 28): Godfrey Care Response. 27th March 2024.

Coroners Concerns Godfrey Care were informed by Mr Burgess’ mother and the Neurology department of Royal Stoke University that the appropriate dose of Brivaracetam was 4ml twice daily. Medication was withheld between 22-26 July 2022 due to the information not being in writing from the prescriber, however the evidence at inquest was that 10ml twice daily was commenced on 26 July 2022 following a call to the 111 service.

Godfrey Care Response We intend to review our internal policies and procedures considering the coroners concerns and identify where changes need to be made. Below, we respond to the coroner’s areas of concern, setting out what we have already done, what we are doing now, and what we intend to do in the future.

Lessons Learned On the 1st March 2024, medication communication and lessons learned session completed with all deputy managers, managers, and senior leaders of the organisation. Criteria covered and addressed:
• Emergency admissions
• No labels on medication
• Parents stipulating what agreed dosages are.
• Specialist prescribers (such as neurologists)
• GP prescriptions that differ to specialist prescribers
• Triangulation in these circumstances.
• Run through the reviewed managers monthly medication audit to ensure expectations are clear. The session was an opportunity to review the effectiveness of Godfrey Care medication procedures, identify what works well and what needs improvement. Key findings and recommendations:
• Weekly medication audits; to be conducted by a competent and trained person such as team leader, deputy manager or manager of a service.
• Verbal medication changes during appointments; written confirmation to be received from the clinician making changes to medication, prior to Godfrey Care staff making any changes to medication. A new prescription to be ordered and received within 48 hours, 72 hours maximum.

Reviewed Policies and Procedures The following actions will be implemented by 1st April 2024.

1. Local Medication policy implementation, in addition to the organisations external provider’s QCS medication policies and procedures (Quality Compliance Systems).

1.1 The local policy is clear in relation to receiving and checking in medication delivered from an alternative provision, other than a pharmacist, such as a family member or a previous care provider. We recognised the need to strengthen our procedure for checking in medication for a person transitioning from a family home or another care provider to Godfrey Care, where medication is not delivered straight from a pharmacist.

9.1 “Receiving and checking in Medication delivered from an alternative provision, such as family member or previous care provider.

All medication to be checked in, check the medication against the MAR sheet given if supplied and document on the back of the MAR the date, the individual medication name and dosage, quantity received and sign.

If the person has moved in with no MAR sheet, (see section 6, transcribing) medication prescribed (transcribed from medication labels), dosage, quantity received, to be handwritten on a new MAR sheet with the details of the person clearly documented at the top, date of birth and any known allergies etc. and signed by two medication competent staff.

If a label has been altered in any way or is illegible or has been removed, the pharmacy responsible for dispensing the medication should be contacted and new prescribed medication labels to be requested. If there are further issues with the prescription labels, then an appropriate health professional must be contacted immediately, and their advice sought before the medication is administered. Medication prescribed dosages must be received in writing by a prescribing clinician prior to administration of medication (see section 18, remote prescription, or direction to administer). Any medication dosages missed, must be reported to an appropriate health professional for their advice, and a safeguarding referral made.”

1.2 The local policy is clear in relation to remote medication prescription or direction to administer made by a GP or other clinician. We recognised the importance of triangulation where multiple prescribers are involved with a person we support.

“18. Remote prescription or direction to administer.

At times medication changes mid cycle may be agreed with a GP or other clinician such as neurologist, psychiatrist, or dentist.

A verbal order to change medication is not acceptable on its own. The fax or email prescription or direction to administer must be stapled to the service user’s existing MAR. This should be followed up by a new prescription within normally 48 hours (72 hours maximum – bank holidays and weekends). In any event, the changes must have been authorised (via text, email, or fax) by a registered prescriber before the new dosage is administered.

Triangulation: where it is a clinician’s responsibility to send the update of changes to a GP surgery, to enable them to update the prescription, this should be followed up with the surgery to ensure the appropriate changes are made and a new prescription ordered.

Suitably trained persons should note that remote prescribing cannot be undertaken in a care service because they do not have access to a stock of medicines.”

2 The Weekly Medication Audit and Monthly Managers Medication Audit already include a check for legible labels, and have been reviewed to include the following prompt to check: “Any prescribed medication changes mid cycle has been agreed with GP or other clinician such as neurologist, psychiatrist, or dentist. Written confirmation has been received as evidence to make the changes, and a new prescription with new dosage received withing 48 hours, 72 hours maximum?”

3 The Staff Medication Competency Assessment has been reviewed and now includes the following questions. “Can the colleague explain the appropriate steps they would take to clarify unclear or illegible directions? Can the colleague explain the steps they would take if the MAR instructions differed to the instructions on the label of the medicine? Can the colleague explain the protocol for verbal changes to medication following an appointment?”