Dear Ma'am Re: Regulation 28 Report to Prevent Future Deaths Claire Medhurst (deceased) We refer to your report issued following the inquest touching upon the death of Claire Medhurst dated 10 August 2017 pursuant to Regulation 28 of the Coroner's (Investigations) Regulations 2013. The follow is our response in relation to the matters of concerns raised: The Discharging Doctor did not provide any cautionary advice as to further use of analgesics such as paracetamol or ibuprofen The Trust accepts that more should be done to ensure that patients presenting at the Emergency Department (ED) who have had an overdose are provided with appropriate information about paracetamol overdose and precaution around the use of other drugs that contains paracetamol. The action taken with the learning from this case is described as follows: All relevant staff will receive feedback via the appropriate staff meeting: These meetings are already scheduled and all clinicians within the Emergency Department and the acute assessment areas will receive the information through the staff briefings. All staff will be given an overview of the case and the importance of providing essential information to patients and their families on the use of drugs containing paracetamol and ibuprofen will be detailed 2 The importance of providing essential information about paracetamol overdose and precaution around the use of other drugs that contains paracetamol upon discharge has been discussed in the Emergency Department daily safety huddles to ensure that all members of staff are aware of the importance of providing such information 3_ Staff are required to record the advice given to patients in the patients' medical notes. A spot check audit will be undertaken and this will take place regularly in order to ensure a consistent change in practise can be evidenced The results from the first of these audit results is attached as appendix 1 The audit will occur monthly until the Directorate Governance Committee is assured that this practice is fully embedded and sustained. Best of care Best of people key "

4_ An information leaflet has been developed and will be ratified via the Directorate Governance Board on 6th October 2017 . Once ratified, leaflets will be printed and available in the ED on 23r October 2017 . Patients will receive this information as part of their medical management and discharge plan: Staff will include in their documentation that a leaflet has been given and fully explained to the patient. Once implemented, this will be included in the monthly audit programme The patient paracetamol overdose leaflet is attached as appendix 2 . 5_ All patients with an overdose must be reviewed by the nurse in charge of the departmentlacute assessment wards to their transfer or discharge. This will ensure that the patients' medical management and discharge plan has been fully implemented: In the case of paracetamol overdose this has been included in the revised standard operating framework (appendix 3). The Trust adhere to national poisons guidance and access to this is available to all staff working in the EDlacute assessment areas The treating clinician did not receive an alert from the haematology laboratory for the abnormal results for ALT and toxic levels of paracetamol: An investigation into the serious incident was conducted by the head of the biochemistry and pathology department and immediate actions implemented following the outcome of the investigation: Summary of investigation On 27th January 2017 blood samples were taken from the patient and a request was made to the laboratory at 17.23 hours to test for U&E, liver function, CRP and amylase. At 18.25 hours the clinician in the Emergency Department telephoned the laboratory to request a further test for paracetamollsalicylate levels. The sample was analysed, authorised and available t0 clinicians in the Emergency Department on the ILAB web system at 19.00 hours. The investigation concluded that this process was managed to the expected standard. There are existing protocols in place with regards to the actions required by staff when ALT levels are outside the safe limits. In the case of Clare Medhurst, the ALT level was above the limit and the paracetamol level was also above the SBAR limit: This required the technician to telephone the requesting clinician with the results_ There was no evidence in laboratory records that either of these results were communicated to the requesting clinician The investigation included interviewing the member of staff that received and processed the specimen. On examination of the records it highlighted the SBAR form was not completed in accordance to the SBAR reporting protocol. The Trust SBAR system to bleep critical results requiring immediate action to doctors is attached as appendix 4. The analyser repeat log for that day was available but there was no record of the actions taken given the abnormal blood result: Best of care Best of people prior

Actions taken to address issues raised are: 1 _ On 4th September 2017 , the outcome of the investigation was shared with the staff involved in the incident. The member of staff was able to conclude a reflective practice and has demonstrated learning from this incident and that their usual standard of work is in line with Trust policy 2 As a result of this incident an algorithm has been written to add a paracetamol to phone' trigger test: Furthermore, on the first occurrence of an ALT level outside of the safe range (>825) , the system a reminder t0 the laboratory staff to telephone it through to the requesting clinician: This flagging system was implemented on 5"h September 2017 and applies to all tests were the levels are outside of the safe range and require immediate actions by a clinician The Biochemistry Department 'when to telephone a result' document is attached as appendix 5_ 3 audit will be conducted in October 2017 to measure compliance with SBAR and associated protocols, and ensure Trust procedures is adhered to_ have also taken the opportunity to share with you in appendix 6 the Trust serious incident report and integrated action plan which is currently in draft form awaiting CCG approval: