Dear Ms Boyle Paul David Ryley The NPIS has now been able to examine the evidenceyou provided about this case, as well as our own records which include details on use of the TOXBASE database by registered NHS users including the Emergency Department that managed Mr Ryley _ Specifically in relation to the advice on TOXBASE and its use by this hospital: The patient presented 10 April 2018 at 10.47 Dr Benson reviewed the patient at 12.15 and again at 12.54. The TOXBASE management page for paracetamol was accessed by that Emergency Department at 12.47. We cannot guarantee that TOXBASE was accessed with respect to this specific patient but given the timings it does seem likely: The patient re-presented on 11 April 2018 at 11.12_ Dr Wijendra reviewed patient at 12.21. (appropriate)TOXBASE management page for patients presenting more than 24 hours after ingestion was accessed by the department at 12.18. The ble page was also accessed at this time: Again; we cannot guarantee it was accessed with respect to this patient but it does seem likely given the matched timings. There is a very small possibility of another patient presenting more than 24 after ingestion of paracetamol being managed in the same department at the same time: Within this TOXBASE entry for patients greater than 24 hour after ingestion the advice clearly presented in point 2 is to checkall bloods: TOXBASE guidance for acute paracetamol overdose is clearly set out for different time intervals after ingestion. There is no suggestion that advice would apply only to an initial presentation, contrary to assertions made during the inquest. Also, the NPIS provides a 24/7 telephone advice line that health professionals can use if they are uncertain as to the management ofa patient who may have been poisoned. Nevertheless, in view of the coroners advice, we have added a further statement to the paracetamol index in' our TOXBASE guidance as follows If the patient re-presents following assessment and discharge, manage as per a new presentation: We hope that the information provided is useful and that the actions we have taken deal adequately with the coroner' s Regulation 28 Report: