Dear Mr Cooper

Inquest touching the death of Lilian Board

Thank you for providing us with a copy of the Regulation 28 Report to Prevent Future Deaths. This letter is the response from United Lincolnshire Hospitals NHS Trust (ULHT).

Firstly, at the outset, the Trust (and myself personally) would like to express our heartfelt condolences to Mrs Board’s family and friends for their loss.

Response to issues raised by the Report

Firstly, as a personal point of clarity in case this is relevant for any future reference, at the time of this patient’s admission to ULHT and her subsequent death, I was off on extended sick leave receiving treatment for cancer, and my position was covered by as interim Medical Director for ULHT from September 2022 to September 2023, after which I then returned back into my substantive Medical Director role.

I note that your concern is around the prescription of by Mrs Board’s GP and her discharge from hospital on 18 January 2023 where she was also prescribed . Mrs Board therefore had two prescriptions of the same medication that she used to end her life. You asked if there were any checks in place to avoid duplicity of prescriptions between the hospital and GP.

It is important to point out that the policy of the Trust (Policy for Medicines Management Supply of Medicines), in agreement with Lincolnshire Primary Care colleagues including the Primary Care Networks, the Local Medical Committee and the Integrated Care Board, is that we supply patients with 14 days supply of medication as a default at the point of discharge, This is not unusual, as almost all acute provider Trusts within NHS England have similar policies to dispense medication supplies upon discharge, with these supply arrangements ranging anywhere between 7-28 days depending on policies of the specific NHS Trusts. A degree of duplicity is accepted in this regard, as the vast majority of patients discharged with a component of overlapping medication to ensure non-interruption of supply will simply continue one lot of prescribed medication until this has been completed then switch over to the other medication prescription, and patients are counselled about doing this on a case-by-case basis.

With regard to this particular case, I can confirm that a box of was dispensed (

) in accordance with that policy. For further clarification, Trust staff have access to the summary care record, however pharmacy staff will check the validity of the prescription from the dispensary, but they do not perform medicines reconciliation from the dispensary. The nursing staff in conjunction with pharmacy staff (when appropriate) will however ask the patient what medication they are already on, on admission and for example if they are running out of any particular medication. Nursing staff will then check medication at the point of discharge to ensure that patient has their own supplies (or not) and that the drugs are as prescribed on the discharge letter, and how to deal with overlapping supplies.

The reason for why such components of the relevant policies are required is that we have an overarching duty of care to ensure that patients do not come to harm by having an interrupted regime of treatment in the intervening period of time between being discharged from our care and then seeing their GP for an amended prescription, which can often practically take 1-2 weeks (and in some circumstances, even longer than 2 weeks). Significant harm can occur in circumstances where drugs for
e.g. heart disease / stroke / epilepsy / depression are interrupted in this fashion even for only a few days, which is well recognised.

We therefore do have to balance ensuring patients are discharged home with a sufficient supply against the unusual circumstances of this particular case, where I gather the patient may have deliberately misled to circumvent processes in both primary and secondary care. Regarding that balance, it is considered that many more patients could (and would) be harmed if they are discharged without a supply of medication and then are entirely reliant on making timely arrangements (which is often beyond their control) to seek a supply of dispensed medication via their General Practitioner. GP representative bodies themselves are very clear both locally and nationally that secondary care have the onus and responsibility to ensure that patients are discharged from hospital with medications on that basis to avoid inadvertent cessation. Having discussed this case with our Lincolnshire system Medical Director colleagues in the Primary Care Local Medical Committee and the Integrated Care Board, they concur with that consensus and maintain the opinion that the current Trust policy and arrangement remain appropriate.

I note that in Mrs Board’s case, it is estimated that she took approximately tablets, so even if ULHT had not discharged her with a further 14 day supply, that estimate implies that she would have still had a minimum of tablets in her possession not dispensed by our Trust, which would in itself have been a likely fatal dose in overdose.

We hope that this response has addressed the concerns you have outlined. However, please let me know if you have any further concerns or require any further clarifications around the nuances of this, and I will of course address these accordingly. In addition to the usual communication channels, I can be contacted via telephone / Teams etc if you feel that might be more helpful depending on what is required in that circumstance.