Dear Mr Gittins Re: Inquest of Nancy Hughes Regulation 28 of the Coroners Regulations 2013 Following the conclusion of the above inquest and receipt of the Regulation 28 of the Coroners (Investigations) Regulations 2013 Report; you expressed two concerns and instructed the Health Board to take action to prevent further deaths will address each in turn detailing the following actions:
1. There was no review of her medication in accordance with accepted medical practice and no system in place to ensure that this was undertaken: This is a requirement under the Mental Health (Wales) Measure; there is a requirement for patients to have named individual who coordinates their care, ie their Care Coordinator: For patients known to community teams their care coordinator will be a member of staff from that team, this could be a Consultant; a nurse, a social work or other professional: For patients not previously known to community teams prior to their admission, a named nurse (care coordinator) must be allocated to that patient within the first 24 hours of the admission this is part of the patient's 7 day admission pathway: The care coordinator, or named nurse have responsibility for maintaining contact with the patient and the care team looking after the patient; if are transferred for medical treatment into an acute hospital setting: This would include review of medication BCUHB Mental Health Medicines Management Group has developed Prescribing Guideline for the Management of Behavioural and Psychological Symptoms of Dementia The guideline states: "Monitoring Following prescribing the patient should be reviewed at least weekly for in- patients and 3 monthly in primary care_ Where the antipsychotic was started by the consultant and the GP is asked to provide ongoing review this must be clearly documented in the letter to the GP giving clear guidance on when and how to reduce the medication_ Cyfeiriad Gohebiaeth ar gyfer y Cadeirydd ar Prif Weithredwr Correspondence address for Chairman and Chief Executive: Swyddfa'r Gweithredwyr Executives' Office Ysbyty Gwynedd, Penrhosgarnedd Bangor; Gwynedd LL57 2PW Gwefan: www-pbc cymru nhsuk Web: wwwbcu.wales nhs.uk they

Review and Discontinuation At 6 or 12 weeks: The review should be directed towards the target symptom for which the medication was prescribed_ If target symptoms have improved and the behaviour is settled, the medication should be gradually reduced e.g: by reducing the dose by 50% or the smallest increment possible every 2 to 4 weeks until the medication has been stopped_ If symptoms return then continue the lowest beneficial dose. Where no improvement is noted, consider slowly decreasing the dose and consider an alternative antipsychotic or seek specialist advice. Continue to review regularly while remaining on treatment Guideline is embedded for information. BCUHB Unliensed Antipsychotics in Den 2 _ That the evidence given by Consultant Orthopaedic Surgeon suggested that there was no cohesion between mental health treatment and medical treatment such that whilst receiving medical treatment he would not have access to mental health information relating to patient and as a result there may be no consideration given to the care given to vulnerable patients requiring additional support: The role of the Care coordinator or named nurse incorporates responsibilities for ensuring effective communication between the transferring ward and receiving ward. When patients are transferred from mental health facilities to an acute secondary care setting; mental health medical records should follow the patient The Mental Health Improvement Group is also working to improve this_ hope these actions are sufficient to reassure you, but trust should you require further information you will not hesitate to contact me further: