Dear Coroner,

Re: Regulation 28 Report to Prevent Future Deaths – Graham Thomas John Smith who died on 7 March 2023.

Thank you for your Report to Prevent Future Deaths (hereafter “Report”) dated 7 September 2023 concerning the death of Graham Thomas John Smith on 7 March
2023. In advance of responding to the specific concerns raised in your Report, I would like to express my deep condolences to Graham’s family and loved ones. NHS England are keen to assure the family and the coroner that the concerns raised about Graham’s care have been listened to and reflected upon.

In your Report you raised the concern that there is a risk that there could be a national lack of awareness from clinicians of Myasthenia Gravis and its contraindications. This was because the Serious Investigation Report commissioned by University Hospitals Birmingham Trust, and which you heard at inquest, raised that there was a lack of awareness within the Trust which, as you say, is a large Trust in a metropolitan area.

The antibiotic, Gentamicin, which was administered to Graham while he was in the Emergency Department is clearly contraindicated for patients with Myasthenia Gravis (MG) in the British National Formulary (BNF). The BNF is a joint publication of the British Medical Association (BMA) and the Royal Pharmaceutical Society with the purpose of providing prescribers, pharmacists, and other healthcare professionals with sound up-to-date information about the use of medicines. The Summary of Product Characteristics within the electronic medicines compendium (emc) also makes clear the risks associated with Gentamicin and other antibiotics in patients with MG. The emc contains up to date, easily accessible information about medicines licensed for use in the UK. Both the BNF and the emc are well-known and trusted resources for medical professionals. My national Patient Safety colleagues have also advised that many Trust prescribing guidelines and/or patient information leaflets do raise the risk of Myasthenia Gravis contraindications, and I include some examples here: Policies and Procedures Trust Framework (gloshospitals.nhs.uk), PI_7-Aminoglycoside- antibiotic-therapy.pdf (royalpapworth.nhs.uk).

The issue of patients not receiving their normal medications (in this case, Pyridostigmine) while in an emergency hospital setting falls into the omitted and delayed medications category. This is an issue that specialist pharmacy service colleagues are currently in the process of developing new guidance to address and NHS England can undertake to update the coroner once this new guidance has been published. NHS England is also aware that the Royal College of Emergency Medicine National Medical Director NHS England Wellington House 133-155 Waterloo Road London SE1 8UG

25 October 2023

(RCEM) are preparing a Safety Flash to raise awareness of delivering time critical and important medications when patients are in Emergency Departments for long periods.

My regional colleagues in the Midlands are also in the process of engaging with Birmingham University Hospitals Trust and Birmingham and Solihull Integrated Care Board on the concerns raised in your Report and what local actions have been identified and will keep national NHS England colleagues updated on the status of this. You may also wish to contact the Trust directly.

I would also like to provide further assurances on national NHS England work taking place around the Reports to Prevent Future Deaths. All reports received are discussed by the Regulation 28 Working Group, comprising Regional Medical Directors, and other clinical and quality colleagues from across the regions. This ensures that key learnings and insights around preventable deaths are shared across the NHS at both a national and regional level and helps us pay close attention to any emerging trends that may require further review and action.

Thank you for bringing these important patient safety issues to my attention and please do not hesitate to contact me should you need any further information.