Dear Mr Sowersby, I am writing in response to the Regulation 28 Report to Prevent Future Deaths dated 8 September
2023. Thank you for providing the Trust with the opportunity to further consider the concerns you have raised. We recognise the importance of continuously reflecting upon our current practice in order to identify action we can take to improve patient safety. To that end, I have requested the assistance of the Divisions involved in the deceased’s care, and the Chief Medical Officer, to address your concerns, as set out further below. HM Coroner’s concerns:
1. The ITU system where medicines are prescribed does not talk to an electronic medicines system in the rest of the hospital. I understand that your concern has arisen from evidence given by an ICU Consultant at the inquest. It may be helpful to explain the local and national context of the systems, in order to provide assurance to you in relation to this issue. In UHBW the ITU electronic record system (Phillips ICCA) is a specialist critical care system that provides full electronic records of the complexity of care delivered to patients in intensive care, including a complex prescribing function. For patients in the ward areas of our hospitals, medicines are currently prescribed using paper drug charts. A Trust-wide system for electronic prescribing and medicines administration, Careflow Medicines Management (CMM), for ward based patients is currently being implemented across

UHBW where it will be used across most of our clinical areas. This excludes intensive care units, theatres and the central delivery suite at St Michael’s Hospital because CMM does not have the functionality to safely manage variable infusions typically used in these areas. The CMM system will introduce a range of additional risk controls to prevent prescribing and administration errors such as a second check for controlled drugs, allergy checking, interaction checking and therapeutic duplication warnings. The timeline for this is subject to confirmation with external suppliers. In addressing transcription challenges within the different clinical areas of UHBW, it may seem desirable to have a unified prescribing system. However, it’s important to acknowledge that the Electronic Patient Record system used for ward-based patients would not be suitable for use on ITU given the specialised requirements of the Intensive Care system. This challenge is not unique to UHBW; across the NHS, different clinical areas, including ITU, maternity, and pathology, often operate with disparate systems due to their complex, individual requirements. We have also considered the possibility of integration and data-sharing between the specialised ITU system (Phillips ICCA) and the Electronic Patient Record system used for ward-based patients. Unfortunately, this pursuit is significantly complicated by intricate and multifaceted obstacles. For example, one notable challenge is the harmonisation of drug formularies across systems to enable the transfer of information. ITU prescribing demands a level of complexity far exceeding that of ward-level prescribing. Maintaining this heightened complexity within the Electronic Patient Record at ITU standards would require extensive, ongoing effort and would inadvertently introduce unnecessary risks into ward-level prescribing practices. In addition, achieving interoperability between the two systems would require extensive technical input from and between the two external competing commercial providers, which would be outside of the Trust’s control. We recognise that management of medical records and prescriptions across the Trust is a complex issue, particularly where different systems are in use across different specialities. Unfortunately, for the reasons set out above, it is not possible to introduce a unified electronic prescribing system at this time.
2. The physical transcription of each patient’s medication list on step down from ITU and the limited number of people who can perform this task. Medicines reconciliation, as defined by the Institute for Healthcare Improvement, is the process of identifying an accurate list of a person's current medicines and comparing them with the current list in use, recognising any discrepancies, and documenting any changes, thereby resulting in a complete list of medicines, accurately communicated. At transfers of care, such as stepdown from ITU to the ward, this includes clinical decision making about starting, restarting, stopping, or changing prescriptions for medicines. Even with a unified prescribing system extending from critical care to ward based settings, it would still be crucial that a qualified individual carefully reviews and approves medication adjustments.

As there will always be a need for a human element in a system for transcribing medicines between care settings, mitigation at UHBW is focussed on reducing risk as far as is possible, for example, by providing optimum possible conditions for this task and staff with the appropriate expertise. Actions already in place to reduce the risk of transcription errors between ITU and the wards:
• Prescribers completing the ward drug chart obtain a second check from a doctor.
• Routine training for junior and rotational ward pharmacists receiving ICU step down patients.
• Designated quiet transcriptions space.
• Routine application of standard analgesic regimen labels for surgical patients.
• Training for prescribing delivered by a pharmacist at the new doctor induction for each rotation.
• Participated in a regional audit to share learning from other Trusts and identify potential new opportunities for reducing risk of medication errors at step down. Additional actions UHBW are taking to reduce the risk of transcription errors:
• Introduction of CMM will reduce the risk of transcription between wards at UHBW and other medication errors by providing a standardised formulary with standard regimen templates and electronic calculations that will promote best prescribing practice; whereas transcribing to paper is open ended with no prescriber feedback.
• Introduction of CMM will improve efficiency of medicines reconciliation by providing the ability for remote checking and medicines reconciliation.
• You heard in evidence that proposals for additional resource in Pharmacy were presented but, regrettably, there were competing proposals from higher risk areas, which the Trust had to prioritise. I asked the Chief Medical Officer to oversee a review of the funding requests, and entries on the Trust’s risk register, to provide further assurance around this. I confirm that the Trust will invest in additional pharmacy staff for adult ITU to ensure all medicines reconciliation at step down is completed by a suitably trained individual. This will provide a pharmacy medicines reconciliation five days a week. In addition, this investment will provide a safety net review of weekend medicines reconciliation previously undertaken by doctors and advanced nurse practitioners at the weekend at the time of transfer out of ITU. Kind regards,

Chief Executive