Dear Ms Jones,

Inquest into the death of Mrs Lottie Reid – Report to Prevent Future Deaths

I write in response to the Regulation 28 Report made by you following your investigation and inquest into the death of Mrs Lottie Reid on 9 and 24 June 2015 and your letter to Mr Andrew Foster, Chief Executive.

I am responding in my capacity as the Trust Executive Medical Director & Deputy Chief Executive.

The Heart of England NHS Foundation Trust (the "Trust") has carefully considered the important matters raised by you at the inquest and I set out the Trust's response below:

1. That following discharge from Good Hope Hospital to Perry Trees Intermediate Care Centre the Printed Electronic Prescribing Medication Admin Chart ("PEPMAC") did not mirror the medication referred to in the Discharge Letter and Prescription.

2. There did not appear to be a protocol in place whereby such discrepancies could easily be checked and this appeared to be especially difficult to do at weekends.

The Trust is aware of the importance of ensuring that there is clarity in relation to the medications prescribed whilst in hospital, and on discharge into the community or to an intermediate care facility. It is for this reason that the Trust has a procedure for discharging patients into intermediate care (the "Intermediate Care Procedure"). Enclosed is a copy of the Intermediate Care Procedure for your consideration.

As you are aware, the medical staff are not permanently present at the intermediate care facility, which clearly impacts on their availability to prescribe a given medicine (although it is common practice for intermediate care facilities to be staffed in this way). Without medication being appropriately prescribed and documented on a Medicines Administration Chart ("MAC") (also known as a PEPMAC), nurses are unable to administer the medication.

I understand that the Trust Intermediate Care Procedure requires patients to be discharged to an intermediate care facility with a MAC chart. The MAC chart should be reviewed by the doctor at the same time as the To-Take-Out ("TTO") is written up to reflect the medicines required at discharge as opposed to the medicines being taken during admission.

Regrettably, in Mrs Reid's case when she was discharged into the intermediate care facility, Perry Trees, there was a discrepancy between the PEPMAC and the discharge letter and prescription.

In responding to your Regulation 28 Report, we have sought the views of the senior responsible clinician based at Good Hope Hospital, (Associate Medical Director) and the Clinical Director and Chief Pharmacist Tania Carruthers.

In order that the risk of future events can be reduced the following steps have been taken by the Trust:

1. On reflection, it was felt that a lack of staff awareness of the Intermediate Care Procedure was a contributory factor. To ensure this procedure is followed in future, the Trust is sending a clinical alert to all wards at Good Hope Hospital by the end of August. By way of context, it should be noted that whilst staff awareness of the procedure was a factor, it appears that this was the first incident of its kind at one of our intermediate care facilities (although that in no way minimises the seriousness of this case).

2. The Trust is amending the nursing discharge checklist to include a reminder to check the PEPMAC.

In addition to strengthening the processes as described above, we consider that this case is an opportunity to improve to the discharge process and the documentation in particular:

3. The Trust is in the process of improving the discharge documentation (known as yellow cards), which is currently used by clinicians discharging palliative care patients to other carers. This procedure requires the treating clinician to write and sign a separate document which details the patient's prescribed medication, which is then used by the treating clinicians on discharge.

This process will reduce the risk of inconsistency in the discharge documents for the patient, as there will only be one document that the clinicians will refer to on discharge. The template will be standardised to ensure it contains the optimal information for safe prescribing and administration.

Once the new documentation has been approved through our governance processes, it will be piloted within palliative care. Subject to feedback from the community staff, a final decision as to the appropriateness of implementing this process for patients being discharged into an intermediate care facility will be made. It is likely that this decision will be made in the next six months, and will be based on clarity of the prescribing and a review of any reported incidents.

4. The dissemination of information about the Intermediate Care Procedure to all wards at Good Hope Hospital will address the issues raised in this case. However, as an additional step, should any inconsistencies arise in future the staff at the intermediate care facility can check the patient's prescribed medication by telephoning the discharging ward directly.

5. In addition, discharge letters (excluding paediatrics and cancer services) include a statement at the bottom that if there are any questions or concerns about the discharge medication they should call the pharmacy Medicines Helpline (0121 424 4682).

6. To strengthen the current pharmacy processes, when available, MAC charts and TTOs are checked for discrepancies. As part of our response, the incident was discussed with the pharmacist involved. The Chief Pharmacist has also reminded all of her pharmacists about the importance of this issue. The Chief Pharmacist is also reviewing existing SOPs to ensure they are robust and fit for purpose.

Finally, in sad situations such as this, it is important that the family of Mrs Reid are made aware of the steps that we are taking to reduce the risk of future events.

If I can be of any further assistance, please do not hesitate to contact me.

Best wishes.