Dear Sir,

Re: Inquest touching upon the death of Mr Michael John Vince

I refer to your letter dated 27th June 2022 and the Regulation 28 report, detailing your concerns related to the care provided by NELFT NHS Foundation Trust (‘NELFT’) as follows:

1. Mr Vince was prescribed with Zopiclone for 20 years, despite the NICE guidelines indicating that Zopiclone is not suitable for long term use.
2. There was no evidence that prescription of Zopiclone was meaningfully reviewed by NELFT’s Community Mental Health team or GP.
3. Evidence of Mr Vince’s dependence upon Zopiclone was not shared by his GP with the Trust.
4. The frequency with which Mr Vince was administering his PRN Zopiclone was never monitored.

We have taken the concerns expressed by you very seriously and undertook further consultations with the Chief Pharmacist and other members of the MDT. On 06/07/22 we arranged a wider NELFT learning review led by our pharmacy department and developed an action plan to address the identified further learning following the Inquest. The event was attended by health care professionals at NELFT and primary care including the practice which was directly involved in the care of Mr Vince.

Chair:

Acting chief executive:

The current practice at NELFT is that whoever prescribes the medication, is responsible for monitoring the compliance with medication administration regime. However, in light of learning from this inquest we have updated our practice as highlighted within the attached action plan and will monitor implementation of the updated practice jointly with the chief pharmacist.

We have agreed a number of actions to address concerns raised by you and enclose action plan detailing the Trust’s efforts to improve the safety and quality of care provided by NELFT.

I would like to express my heartfelt condolences to the family of Mr Vince and sincerely apologise for the shortcomings in care provided by NELFT identified in our Serious Incident report as well as at the inquest hearing on 21st June 2022.

I would also like to thank you for your full and fearless investigation and for raising your concerns with the Trust, enabling us to undertake further learning from the very sad death of Mr Vince.

If you would like to discuss these actions further, please kindly feel free to contact my office on 0300 555 1298.

Dear Mr Re: Inquest Touching the Death of Mr Michael John Vince Regulation 28: Report to Prevent Future Deaths Thank you for sending the Prevention of Future Deaths Report regarding the death of Mr Michael Vince, and providing me an opportunity to comment on the matters of concern raised Before responding; would like to express my sincere condolences to the family of Mr Vince for their loss. have carefully considered the Report: Actions taken by myself and my practice in response to the concerns raised are described below: Concern 1: The NICE guidelines for Zopiclone indicate that it is a suitable medication for the short-term treatment of insomnia, it advises against prolonged use due to risk of tolerance and withdrawal symptoms_ Mr Vince is said to have been prescribed Zopiclone for 20 years: Concern 2: No evidence exists to support that Mr Vince'$ GP or community mental health team meaningfully reviewed his prescription for Zopiclone: Concern 4: frequency with which Mr Vince was administering his PRN Zopiclone was never monitored. Page of 3 Irving; The

Response to Concerns 1, 2and 4 In response to the above concerns, the following actions have been undertaken: Clinical Audit of all patients prescribed Zopiclone over the past 2 years; The report contains concerns as to the monitoring and review of Mr Vince's Zopiclone response, our practice determined to undertake comprehensive audit and clinical review of all patients prescribed Zopiclone_ A review of practice records for all patients prescribed Zopiclone over the last 2 years was performed_ A summary of the results is as follows: Acute or one-off prescription of Zopiclone 22 patients Repeat prescription of Zopiclone 16 patients All patients currently taking Zopiclone were contacted for a structured medication review undertaken by myself. The review was guided by best practice guidelines for the prescribing of Zopiclone: The result of the medication reviews was that the majority of patients on repeat prescriptions had their repeat prescribing ended. Some patients were referred to the Trust's Mental Health Service for further review and management of their Zopiclone administration: After the initial structured medication review, a second cycle review of patients on repeat Zopiclone prescriptions was undertaken: This showed that only 4 patients remained on repeat Zopiclone. Two of these patients are scheduled for further review, two remain on long term Zopiclone and are scheduled for 6 monthly review. Implementation of z-Drug Protocol have drafted a local practice Protocol for Z-Drugs which has been implemented as at 29 July 2022. A copy of the Protocol is included with this letter. protocol was drafted following my review of best practice guidelines for the prescribing and management of patients o Zopiclone other Z-Drug hypnotics. The protocol includes links to relevant NICE guidelines ad comprehensive resource pack produced by the Greater Manchester Medicines Management Group included as an appendix: It also includes a Good Sleep Guide to assist in advising patients with non- pharmaceutical methods to manage insomnia. The policy requires regular review of patients prescribed Z-Drug hypnotics being minimum of 4 weeks for newly prescribed patients, and at 6-monthly intervals for patients on long term treatment and after review by Mental Health Services_ Discussion and Education of Practice Staff Meetings have been held with practice staff to alert them t6 the new protocol, and to advise them to refer all patients requesting repeat prescriptions of Z-Drugs to myself for medication review. 2 of 3 and The and Page

A notice has been placed in the practice waiting room for the information of patients regarding the practice' s Z-Drug protocol. will continue to monitor the above actions in our regular practice meetings. Concern 3: Evidence of Mr Vince' $ dependence upon Zopiclone was not shared by his GP with the mental health trust. Responseto Concern ? The North East London Foundation Trust (NELFT) Mental Health Service held a stakeholder meeting on 14 July 2022 to discuss the Coronial recommendations, as well as the issue of prescribing of Z-Drugs generally. The meeting included representatives from the NELFT medication safety team was invited and attended this meeting which was a very useful opportunity to discuss clinical collaboration with the Trust regarding patients on z-Drug hypnotics_ At that meeting the importance of proper communication between local GP'$, the NELFT Mental Health Team and other clinical services was discussed. It was agreed that review of hypnotics was the responsibility of the primary prescriber, but also the prescriptions should be reviewed by the Trust clinicians when in the scope of treatment provided by that clinician The Trust committed to undertaking a wider audit of Z-Drug prescribing within the NELFT localities which will be led by the Trust pharmacy services will also be developing a safe - prescribing training package and will include education of local GP's in their roll-out of this package For my part, have commenced more proactive referral of patients who appear dependent upon Z-Drug hypnotics for review and advice by specialist NELFT Mental Health services. This has been assisted by the response of the NELFT to the Coronial recommendations and the discussion and collaboration that has resulted_ My practice' $ Z-Drug Protocol includes requirement for structured medication review for patients on long term Z-Drugs with mental health issues, and requirement to notify the Mental Health Team for those patients who request additional Z drugs Thank you again for your referring your concerns regarding the care of Mr Vince: If you would like any further information regarding our response to the concerns, please contact me on emaill