Dear Veronica Hamilton-Deeley, The Late Mr Darren James CARRINGTON Thank you. for your recent letter enclosing a Regulation 28 request following the death of Darren James Carrington. I was very sorry to hear of his death and I hope the following information helps somewhat. In preparing my request, I have spoken with , the CCG Medication Management and Quality and Safety colleagues, as well as clinical and senior admin colleagues from a linked GP Practice - who have provided support and advice to and his team. I have been encouraged by open and constructive response to events, and his offer to participate in the CCGs Task and Finish Group (as proposed in previous correspondence) is welcome and I am confident will be of benefit to all of primary care. Brighton and Hove has above average numbers of deaths relating to misuse of prescribed medication. Alcohol and recreational drug misuse are often factors. As you have outlined, the Primary Care workforce has changed, with more salaried, locum and less than full-time posts. Those signing prescriptions are less likely to have personal knowledge of patients and it is essential to have robust processes in place to ensure patient safety. When Practices acquire new IT systems or upgrades, initial training is often limited. It is important that staff have access to ongoing structured training around optimal use of the system, as in-house digital knowledge can be variable.

Patients are increasingly obtaining medication directly via the Internet. My understanding is that this was the case with DC. Questioning if patients are obtaining medication via this route needs to become a standard part of the consultation. I can confirm that the following changes have been implemented at North Laine Surgery via a Practice Meeting attended by all staff: ­
• All reports of patient self-harm are now circulated to clinical staff.
• Review of best practice for coding self-harm.
• Increased awareness of potential significance of frequent requests for apparently small quantities of medication.
• All patients receiving Zopiclone have had their records audited. No evidence has been found of other patients over ordering. Quantities of medication have been reviewed as appropriate.
• Records of all patients receiving weekly prescriptions have been reviewed and access to on-line requests have been removed.
• Records of all patients receiving prescriptions for CDs or drugs of potential abuse or dependency, have been reviewed and access to online requests removed.
• Arrangements have been made to ensure administrative and clinical staff have adequate, protected time to manage prescription requests.
• Ongoing discussions with linked Practice around sharing high risk medication review protocol.
• Computer settings changed with a view to lower thresholds for flagging up early ordering of scripts and increased awareness around the potential significance of these and other alerts.
• The importance of appropriate 'maximum number 'of repeats authorised with a view to triggering a clinical review of cases. Our Medication Management team are providing ongoing support. In particular, around embedding The High Risk Drug review protocol mentioned above, as well as ensuring that the new Practice Repeat Prescribing Policy covers current best practice. I am confident that the measures outlined will significantly reduce the chance of future related patient harm at North Laine Surgery. It is however, essential that the learning is shared across the city. The Task and Finish Group's membership will include Community Pharmacy Representatives, CCG digital staff, Practice Managers as well as Primary care Clinicians with a view to ensuring maximal learning from this case is embedded across the city. You raise the important issue to what extent Community Pharmacists provide an additional level of safety. Representatives of the Local Pharmaceutical Committee have agreed to attend the Task and Finish Group during which we will highlight this role and the importance of a joint approach.

Finally, the Practice are in the process of completing a serious incident investigation report that will be submitted to NHSE. Any further learning from this will be disseminated locally via the Task and Finish Group. Please do not hesitate to contact me if you require any further assistance. Kind regards,

Clinical Chair Brighton and Hove Clinical Commissioning Group

Dear Mrs Hamilton-Deeley, We are writing in response to your Regulation 28 Report sent to the practice following the death of Mr DC. First of all, I would like to say how saddened everyone at the practice is by the death of Mr DC. He had been a patient of the practice for many years so many of us knew him well and had tried to support him with his difficulties during his life. Both the Practice Manager, and I have been involved in investigating the matters of concern outlined in your Regulation 28 Report, together with all the other doctors and administrative staff in the practice. Therefore, this report is being written jointly by and me and it has also been read and approved by my partners in the practice,

. As is apparent from evidence available to the inquest and the investigation of the Police Liaison Officer, Mr DC was able to obtain scripts for Zopiclone from the practice earlier than scheduled. He did this by making electronic online requests which were processed by the practice and sent electronically to the pharmacist for dispensing. Despite looking into the computer system records, it remains uncertain whether electronic warnings about scripts being ordered too early were always triggered during this process. The settings on the computer, put in place when the system was installed in 2013, allowed scripts to go through within seven days of the due date without an alert or warning being triggered. My recollection is that Mr DC was on a shortened repeat period, i.e. not 28 days but 7 or 14 days so a repeat script could have gone through without a warning/alert being generated. Similarly, patients were able to make an on line request for an item on their repeat prescription list within 10

Actions taken so far taken in response to Section 28 notice served by HM Coroner on North Laine Medical Centre:
1. A significant event analysis attended by the whole practice was held on 22nd May, 2018 to discuss the issues raised by the case. An action plan of 10 items was drawn up which has been read and signed by all participants in the prescribing/repeat prescribing process.
2. An audit of all patients on Zopiclone was carried out to ensure that limits and doses were correctly entered on the system. There was no evidence that any other patients had over- ordered or done so too early.
3. Access to online requests for controlled drugs has been removed for all patients. Following discussion with the patient and their doctor, this may be restored if the patient is considered "low-risk".
4. An investigation into on line ordering and script generation by the computer system was conducted in conjunction with the practice IT co-ordinator. As a result, the timings were changed within the system so that warnings about scripts being ordered too early were changed from 7 to 1 day and ordering online from 10 to 3 days.
5. Patients who overdose will be added to the weekly script list.
6. There has been an extensive revision of the practice prescribing policy incorporating suggestions from the CCG pharmaceutical adviser and we are having a practice meeting on 24th July to discuss further. We look forward to working with her again over the next year to improve further our systems.
7. There has been a raised awareness of the potential of any patient to over-order medication, whether by accident or design.
8. will continue to liaise with the CCG and other groups and will be a member of the T and F group looking into these issues. As part of this, he had a meeting with , the chair of the CCG, on 23rd July where the issues involved were discussed and he seemed supportive of the practice's efforts to address the problem. has seen a draft of the report to be submitted by and feels it accurately reflects the actions and changes made by the practice.
9. A whole practice meeting took place on 24th July to discuss the updated practice prescribing policy . Ongoing review of patients on controlled drugs will occur and a plan to reduce and/or stop agreed with the patient. This will complement what the practice already has put in place over the past 2 years in terms of reduction programmes for patients.
10. A further meeting is planned with the practice IT coordinator to highlight automatically patients who have taken an overdose when certain high-risk drugs are requested. We hope to have this in place shortly.
11. We have self-referred as a practice to the GMC and are also liaising with NHS England and the CQC. We will be submitting a full report to NHS England at some point in the future.

Action plan following meeting held on 22nd May which have been implemented by the practice.
1. All GPs are to be copied into reports of overdoses or other suicide attempts. This is the responsibility of the GP initially receiving the correspondence.
2. All overdoses or suicide attempts are to be coded into the system. We are looking to set up some kind of computer generated warning for patients who fall into this category but will need to liaise with the CCG/national computer system as to what information is appropriate/desirable to include
3. Receptionists and GPs are to be more aware of the possibility that patients may be ordering scripts too early, even if amounts appear "small".
4. An audit of all scripts for Zopiclone, was undertaken to ensure that the correct minimum number of days between script issues is entered on the repeat template. No evidence of any other patient ordering too early was found. Amounts of some prescriptions have been reduced .
5. Any patients on the practice's weekly script system have been reviewed and their access to online prescription requests removed. The practice remains in control of the issuing of the script and ongoing reductions in certain medications is continuing.
7. All patients on controlled drugs or drugs of potential abuse/dependence are being assessed and their access to online requests for prescriptions removed.
8.The receptionist processing repeat prescriptions for the day is to be given allocated and protected time to process the scripts and the same will apply to the doctor signing them off. Receptionists have been reminded that the turnaround for prescriptions is two working days and not to feel pressurised to take less time.
9. We will discuss St Peter's Medical Centre's protocol for high risk medication and how we might use this in the practice, particularly around medication reviews.
10. Timings changed on computer system for warning about scripts being ordered too early to appear from 7 to 1 day before script due and ordering on line from 10 to 3 days.

North Laine Medical Centre Repeat Presc:ribing Policy
1. AIMS The purpose of this policy is to ensure that a simple and clear process for issuing repeat prescriptions is understood within the practice. That clinical control is properly exercised, risks for patients are reduced and the most cost-effective medication is issued on time to meet patient need.
2. Management control All repeat medications are recoded on the practice GP System. Controlled drugs are covered by the 'benzodiazepine prescribing policy'. Medications issued on home visits will be recorded by the GP once he/she has returned to the practice.
3. Clinical Control The responsibility of the doctors is as follows: Doctors to make all additions/alterations to prescriptions: Medication should usuafly be prescribed generically, unless contraindicated during the medication review/or advised by Hospital. To be precise with directions e.g. 1 tablet twice daily, rather than as directed, for clarity, and so that over and under-use is apparent. To sign repeat prescriptions for patients at the end ofsurgery. Initiate repeat medications for new patients, review appropriateness (and cost) of medication. Following hospital appointment or discharge, update treatment record and delete obsolete items. Medication linked to problems- All medications should be linked to a problem to be actioned by GPs opportunistically, when doing meds review when putting new meds on system Enter all drug allergies and adverse reactions codes onto the computer. PRACTICE NURSE WILL ISSUE ­ Dressings etc. Diabetic equipment Asthma equipment contraception RECEPTIONISTS WILL ISSUE dressings, etc. requested by district nurses folic acid, ferrous sulphate, Peptac, and Mucaine requested by midwives and other items specifically authorised by GP for specific situations. Delete medication no longer used by the patient. See below Duration of repeat prescriptions should usually be for 28/56 days.

The maximum duration will be 6 issues unless it is a high-risk drug at discretion of Clinician. Reception staff will no longer override the extra issue but will refer to the GP
4. Review dates: patients' medication to be reviewed at least annually, and code Medication review done entered onto clinical record. Patients over 75 years on 4 or more drugs should be reviewed every 6 months. lf reception staff sees that a patient does not have a Review Date, please advise the GP.
5. High Risk Drugs Shared care Drugs Repeat requests for high risk drugs, e.g. warfarin, lithium, DMARDs drugs are managed through the High-Risk Drugs protocol Some high risk drugs are identified as part of the Les 84. Every month a batch report listing the patient on high risk drugs is sent to the GP prescribing lead. Actions are then followed up with Lynn who coordinates high risk and substance misuse prescribing. This is a shared care service and our patients are monitored as part of this specification. Uthium monitoring is performed via a recall system. file:///C:/Users/stempm/Downloads/safe_drug_mon_lcs_0ll_spec_vl.3%20(2 ).pdf Benzodiazepines, Z-Drugs and opiates/other controlled drugs Patients on this group of drugs must request repeat medications either via Email, in writing or completing the side script. See section 6, Reception staff. Patients who are on reducing regimes of medication or felt to be at risk of misusing medication will be placed on the list for weekly scripts. These will be processed by the nominated receptionist and are not available to be requested by the patient. They will be sent to the chemist in four weekly batches of a week at a time. Every four weeks, the medications are reviewed and reauthorized by the GP and reductions made, if appropriate. The practice is investigating the cost of dip testing new patients requesting high risk drugs or others already on high risk drugs as part of their reviews. Additionally, patient included on the SMI LCS are managed in cooperation with the SMIL Nursing Liaison team.
6. Reception Staff. To alert doctors if over or under-use of medication is noticed, (usually written on px request) and pass on any request for new or changed medication to the doctor (usually as a task). The Practice will not supply further repeat prescriptions at shorter time intervals than have been authorised (by GP) without agreeing the reason for the early request, e.g. holiday. 2

Provided there appears to be no problem, a prescription can be generated and left for the doctor to authorise and sign. A list of situations where the GP must be advised are:
1. The clinical system indicates that a review is necessary
2. Any drug requested by the patient is not on their repeat record
3. Any of the following drugs may not be requested electronically. If on repeat then patient must email, complete the prescription side slip or request via their pharmacist.
1. Temazepam
2. Diazepam (Valium)
3. Dihydrocodeine
4. Zopidone and Zolpidem and Tramadol oxycodone
5. Paracetamol and codeine 500/30 preparations, e.g. Solpadol, Zapain, oral morphine
6. All other controlled drugs
4. The item requested has been issued less than one month previously
5. The overall date limit has passed
6. Any request about which the practice staff are concerned or uncertain. If the Review Date has passed, to print the side slip 'medication review due' on the prescription and flag it to the doctor. On EPS a query note appears in the prescribing task list for the prescribing GP to action. The overall date limit can be extended by the receptionist for 1 month. Only on the express authority of the doctor. The doctor decides whether the patient needs to come in for a review of their medication. If not, the doctor updates the Review Date, and enters the code Medication review done. If the patient's usual doctor is on leave, the repeat prescription is issued as normal, and the medication reviewed with the next prescription. Reception Staff are authorised to automatically delete all repeat medication older than 12 months except DO NOT stop seasonal/hay fever/Ventolin/ GTN sprays and Epipens and seasonal medication. Clinicians only will stop prescriptions older 6 months and they will be archived. To make patients aware of the process for obtaining further repeat medications and encourage the use of the Online Patients Access. To Also explain that the Review date is for the doctor to review the medication; they do not automatically need to see the doctor if it says overdue, unless there is a Reminder message.
7. Patients' responsibility 3

Should have a written record of their repeat medication. Repeat requests should be made by ticking the re-order form, or in writing letter or fax, on line or via the nominated pharmacist. Patients should be prevented from over-ordering medicines. If they are unsure whether an item should be continued, they should discuss it ·with a doctor. They should cross off items they no longer use. They should allow a minimum of 2 working days for prescriptions to be ready and enclose a stamped addressed envelope if they want it posted. With the advent of EPS all patients should be encouraged to have a nominated pharmacy.
8. Prescribing Process Patients should give 2 working days' notice of a request for a repeat prescription. 3 working days' notice is required for medications that need reauthorising or are not on 'repeat'. Requests may be made in writing and sent by post enclosing a SAE left at the surgery reception or ordered via our on line patient Access. Where a patient makes a request in person then a repeat prescription request form should be completed. Repeat prescriptions may be posted to the patient, collected personally collected by some pharmacies the pharmacist. Telephone requests will not be accepted unless previously agreed. This policy avoids mistakes in issuing wrong dosage or types of drug and maintains the 'Audit trail'. We will not telephone routine repeat prescriptions to a pharmacist in any circumstances.
9. For efficient use of Electronic Prescribing (EPS2): Note we have now moved to electronic prescribing. The process we follow is: Ensure patient demographic data matches spine data Check that patient has a nominated pharmacy and that this information is up to date and correct, especially where patients have recently moved to the area. Ensure prescribed items are mapped to dm+d Ensure dosage instructions appear on the record in full, not as abbreviations Where a patient receives more than one repeat item, quantities, authorised issues/ review dates should be synchronized. Some medicines are currently excluded from EPS2 arrangements e.g. Schedule 2 and 3 Controlled Drugs including temazepam and tram ado!. 4

When registering patients, they should nominate a Pharmacy or if a Pharmacy arranges consent then the form is sent to the practice and scanned into notes.
10. Administration and Signatures Reception staff will be allocated protected time and should not be interrupted by other staff member or answer patient queries unless the matter is urgent. All repeats not received electronically should be prepared for signature at the end of morning surgery in protected time. All EPS requests are automatically assigned to Doctor. Then signed scripts will be: Posted to patient {include repeat prescription note) Place in 'to be collected' box on main reception desk Retained Pharmacies boxes. Scripts are collected by Ross and other local pharmacies in a secure bag normally daily. Faxed to chemist then posted {only for urgent requests usually via prior arrangement with chemist). Pharmacists will sign for all scripts collected at reception Check ID particularly when collecting controlled Drugs. Persons collecting controlled drugs on behalf of patients should provide a letter of authority from the patient; this can be in the form of an email. Once authority received make a reminder. All medication issued must be recorded on GP system. Please record destination of script /e.g. SAE, Ross. Basic Training is provided in house additionally we did receive one day's formal training from the CCG when we moved to EPS.
11. Acute Re-Authorisation Requests Those requests that cannot be authorised by the prescribing team are tasked to the Duty GP task box to be reviewed and issued accordingly. Any on the day urgent requests are flagged green and the appropriate clinician is advised these are waiting.
12. LOST PRESCRIPTIONS. If a prescription is reported as lost, check the date of issue and any places where it could possibly be - i.e. misfiled, sent to the chemist or an incorrect chemist. lfthe prescription cannot be found reprint the prescription - do not re-issue Make an entry in the patient's notes (quick note) why re-issued the date of the prescription and that it has been re-printed. Write note in book for lost prescription. Patients who report that their medication or prescription has been stolen should report the matter to the police and obtain a crime number. 5

Patients who regularly "lose" their prescriptions should be seen by a GP who will decide if it is appropriate to re-issue the prescription. Under no circumstances must a receptionist re-print or re-issue a prescription for controlled drugs, this must be actioned by the Duty GP/Pharmacist.
13. Uncollected Prescriptions- The Prescription basket should be checked thoroughly on the first week of every month for uncollected prescriptions. This needs to be done to highlight any potential safeguarding issues or problems to the GP. (Old Rxs ie 2 months or over should be passed on to GPs before destroying as GPs should be made aware if patients aren't taking medications. (Record destroyed Rxs in PMR) Mark prescriptions in error, right dick on the medication screen and give a reason of not collected by patient. These are coder 'Prescription not collecte:d 1 Read code browser on S1 14, Medication reviews. The Practice supports the principles of the medication review described in the briefing paper www.medicines-partnership.org/medication-review

We undertake a full medication review with patients usually face to face and occasionally using the patient's full notes. We adopt the following principles:
1. Al! patients have the chance to raise questions and highlight problems about their medicines
2. Medication review seeks to improve or optimise impact of treatment for an individual patient
3. The review is undertaken in a systematic way by a competent person. At this practice, this is always the Doctor. Reviews are triggered annually for al! patients on the chronic disease registers. Additionally, patients on regular repeat medication will be invited in for a review at intervals defined by the Doctor. Normally 6 months the reviews will be at 6 months unless indicated otherwise.
4. Any changes resulting from the review are agreed with the patient
5. The review is documented in the patient's notes.
6. The impact of any change is monitored. MAS Prepared February 2007 MAS/RMcP/MJAS Reviewed July 2018 6

Dear Miss Hamilton-Deeley Mr Darren James Carrington deceased Thank you for your letter dated 15 June 2018 which I know was acknowledged by my colleague on 18 June. I appreciate you did not request a response, other than to acknowledge receipt of your letter, but I felt.it was important to update you on the issues you raised, and I apologise for the length of time this has taken. I am very sorry that Mr Carrington's GP, Sussex Partnership NHS Foundation Trust and Pavilions did not receive adequate information concerning the details of Mr Carrington's mixed overdose and accept that this does not reflect good continuity of care. I can confirm that this has been fed back to , Clinical Director for Emergency and Acute Medicine and to

, Consultant and Governance Lead for Emergency Medicine.

have discussed these issues with all medical staff as part of the Emergency Department regular governance meetings to highlight the issues that arose from Mr Carrington's attendances and the importance of ensuring that discharge letters contain sufficient detail. With regard to sending discharge summaries I agree that these should ideally be sent by e-mail on the same day of the patient's discharge. However, this is a major project for the Trust and there is a considerable amount of work to be done on process and system testing before this can be implemented. We are currently focused on roll-out of the new Medway Patient Administration System and our hope is to implement systems within the next 12 months to allow discharge letters and summaries to be sent electronically to GPs and other partner organisations as required. If you need any further information please do not hesitate to contact me.

I would also like to pass on my condolences to Mr Carrington's family and friends for their sad loss.