Dear Mr Barkley,

Re: Regulation 28 Report to Prevent Future Deaths – Andrew Peter McCALL - 18/9/2018

Thank you for your Regulation 28 Report (hereinafter the ‘report’) dated 1 July 2019 concerning the death of Andrew Peter McCall on 18th September 2018. Firstly, I would like to express my deep condolences to Mr McCall’s family.

Your report identifies that the recent inquest concluded that Mr McCall’s death was drug related with the cause of death given as: (1a) Gastric Aspiration, (1b) Pregabalin and Methadone Use.

Following the inquest you now raise concerns in your report for NHS England to consider regarding the communication between One Recovery Clinic, and Mr McCall’s GP. You noted that One Recovery Clinic relied on the service user to provide details of their GP, and that this information was not then checked or verified.

Therefore you have identified that it could be possible for service users to be prescribed an opiate replacement programme, without their own GP being made aware of this, increasing the risk of inappropriate, unsuitable or harmful medication being prescribed.

You have recommended that a process be put in place to ensure that GPs are made aware when another organisation are managing an opiate replacement programme for one of their registered patients.

In this case the service is provided by One Recovery Clinic, in conjunction with North Staffordshire Combined Healthcare NHS Trust. The lead provider is Addiction Dependency Solution. Substance misuse services are commissioned by the Local Authority, not NHS England or the Clinical Commissioning Group.

One Recovery is the provider of drug and alcohol community services in Staffordshire and is commissioned by Staffordshire County Council The commissioner contact details for the service is therefore Tony Bullock,

Andrew Barkley Senior Coroner Stoke on Trent and North Staffordshire Coroners Chambers 547 Hartshill Road Stoke on Trent ST4 6HF

Professor Stephen Powis National Medical Director Skipton House 80 London Road SE1 6LH

26th September 2019

NHS England and NHS Improvement (anthony.bullock@staffordshire.gov.uk), Lead Commissioner - Public Health and Prevention Health and Care Staffordshire County Council.

Although NHS England is neither the commissioner or regulator of these services, and have no direct responsibility for them, we recognise the importance of the concerns you have raised, and are taking the following action:

Dr Kenneth Deacon, Medical Director for System Improvement and Professional Standards (Midlands) will:

Make contact with the service lead from Addiction Dependency Solutions, and ask that they:
- review their processes for collecting GP data;
- verify GP data provided by service users (to ensure information is sent to the correct practice); and
- review processes for ensuring that relevant information is reliably and consistently shared with the registered GP. By 30th September 2019 Share the above communication with the Local Authority, to allow them to monitor as part of their commissioning responsibility for this service. By 30th September 2019 Write to all GP practices within Staffordshire:
- making them aware of the inquest findings, and the risks this highlights;
- reminding them of the importance of considering whether other agencies might be prescribing opiate replacements; and
- asking them to alert the clinic directly if they receive information relating to a patient not registered at the practice (so the correct practice can be identified quickly). By 30th September 2019

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