Dear Mr. Chipperfield, On behalf of Humankind, please find below our response to the matters of concern to which Humankind were deemed as being party following the inquest into the death of Claire Copeland. Rely upon delivery of a physical prescription document Unfortunately, the County Durham Drug and Alcohol Recovery Service, along with all other community drug and alcohol services, must rely on paper prescriptions as pharmacies cannot legally use faxed copies of prescriptions to dispense from for controlled drugs, including buprenorphine. Further to this, at this time there is no functionality for the electronic transfer of FP10 MDA blue instalment prescriptions. This is a national issue and not specific to Humankind/Spectrum/County Durham Drug and Alcohol Recovery Service. Humankind have continued to escalate this issue, for example with Controlled Drugs Local Intelligence Networks and the Office of Health Inequalities and Disparities, especially during the COVID-19 pandemic where the ongoing need for this to be resolved became especially pertinent. When the functionality for electronic FP10 MDA blue instalment prescriptions becomes available, Humankind plan to implement this across our services at the earliest opportunity, removing the current unavoidable need to rely upon delivery of a physical prescription. The timescale for this change unfortunately sits outside of our control. Allow that delivery be neither witnessed nor confirmed A comprehensive standard operating procedure for all team members delivering prescriptions to pharmacies has been implemented. This includes the mandatory requirement for prescriptions to be handed directly to a member of the pharmacy staff team, obtaining details of the person taking receipt and a signature from that person to confirm delivery. Completed paperwork is returned to the service base and stored for reference and also included within the service’s management information system. Service managers ensure that only team members authorised to do so deliver prescriptions. The authorisation process includes written confirmation that the team member is aware of, and understands, the instructions for prescription delivery. Lack effective mechanism immediately to detect failed delivery

The service’s prescription delivery standard operating procedure states that should it not be possible to directly deliver and confirm delivery of a prescription, the team member should return to their vehicle and make telephone contact with a nominated manager who is on-site within the service base. The nominated manager will be identified before the team member leaves the service base to deliver the prescription and they will be fully aware that they are the nominated contact in case of a failed delivery. The team member making the delivery will ensure they have their work mobile phone and the number of the nominated contact to enable the call to be made immediately upon failed delivery. Lack mechanism to remedy failed delivery During the telephone contact between the team member attempting to deliver the prescription and nominated manager a contingency plan will be agreed. This plan will take into account the individual circumstances of the delivery including known pharmacy availability and the timescale requirement of dispensing from the prescription. Continuity of care for the service user and safe prescription management will be equally paramount in agreeing a course of action. If an effective contingency plan cannot be immediately agreed, the issue will be escalated to the service Area Manager and Clinical Lead for further guidance and resolution. For any failed deliveries on a Friday that cannot be resolved on that day, the service is available on a Saturday morning, enabling an opportunity to remedy delivery and ensure provision for the weekend. Any failed delivery attempt of a prescription is recorded as an incident within Humankind’s incident management system. This system notifies all relevant managers and team members of the incident, creates a review process and supports identification of learning to prevent further occurrences. Humankind recognises the importance of learning from Miss Copeland’s tragic death and are committed to working together with our workforce and other organisations to prevent this from occurring again. We extend our sincere sympathies to Miss Copeland’s friends and family.

CPO/JM/ASW/579103 May2022Mr Jeremy ChipperfieldSenior Coroner for County Durham and DarlingtonHMCoroner’s Office

2. Arrangements … allow that delivery be neither witnessed nor confirmedThis would be within th

I hopethis letter providesthe necessary assurance that Boots has duly noted the gravitas of the concer