Dear Ma'am Inquest touching the death of Devindar Lal SETH write in response to a Regulation 28, Report to Prevent Future Deaths, dated 26 February 2016, which was made at conclusion of the inquest into the death of Devindar Lal Seth_ Barts Health NHS Trust takes Coronial investigations very seriously and am you have had to make Preventing Future Death recommendations and am grateful to you for highlighting your concern and will ensure that action is taken to address this. note that the cause of Devinder Lal Seth's death was multi organ failure as a consequence of sepsis from aspiration pneumonia resulting from a fractured right hip. You raised concerns involving the recognition of the signs of opiate toxicity in Mr Lal Seth: The concern you raised in the Preventing Future Death report is: You felt that none of the ward staff in this instance recognised the effect that the opioid medication was having upon Mr Seth This led to Mr Seth suffering from opiate toxicity. You considered that it would be helpful if there was easily accessible guidance available for staff. We have investigated the above concern and can confirm: Your report has been discussed at the latest Quality and Safety Committee (QaSC) and at the Hospital Management Board at Newham University Hospital. Barts Health NHS Trust: Newham University Hospital, The London Chest Hospital, The Royal London Hospital, St Bartholomew's Hospital and Whipps Cross University Hospital: OISABLEQ the sorry Fouti sTive _

Barts Health [HS] NHS Trust 2 The Pharmacy department is producing guidance for staff relating to the risk of opiate medications, their side-effects and the signs of opiate toxicity. 3_ This guidance will be cascaded to all members of the ward and to medical staff and the communication manager will include the guidance as an article in the Newham University Hospital site newsletter_ The Pharmacy department is producing a 'share the learning' bulletin relating to this incident; this will be shared with all Pharmacists across all Barts Health NHS Trust sites
5. The Acute Pain team in conjunction with the Trust's Pharmacy department are exploring additional options to highlight the monitoring required when using opioid medications This will include additional nurse training in conjunction with improved use of observation charts_ 5_ Newham University Hospital is planning to review all of its Serious Untoward Incidents (SUI's) that were reported from 2013 to date to identify if there are any opiate related SUI's and if the lessons learnt from this incident can be retrospectively actioned_ The clinical lead for Care of the Elderly at Newham University Hospital now reinforces on a daily basis with the Foundation Year and 2 (FY1 & FY2) doctors working in this area the need to recognise opiate toxicity and to escalate when appropriate 8 The Matron for surgery at Newham University Hospital is in the process of retraining all nursing staff in relation to opioid toxicity and is also ensuring that health care assistants, who undertake patient observations, are trained to recognise opioid intoxication: The Trust is aiming for this to be completed by the end of April 2016. am once again grateful to you for bringing this case to my attention and this letter answers the concerns you have raised.