Dear Mr Jones am writing in response to your Regulation 28 Report to Prevent Future Deaths_ issued following the inquest into the death of Patricia Edge, who sadly died on 20 July 2014_ am now in a position to respond to your concerns outlined below as follows - Issue 1 The circumstances including training of staff and Trust procedures in which patient could be prescribed and dispensed an excessive dose of paracetamol on the 14 July 2014_ Issue 2 ~ The apparent lack of any review of the paracetamol dose between 14 and 19 July 2014. Issue 3 The apparent failure to carry out blood tests between 14 and 19 July which would have revealedlconfirmed the possibility of the dose of paracetamol being excessive, again considering issues of training and procedures: Actions taken: Following an investigation by senior managers into your concerns, the Trust has identified that across the organisation there have been variations in respect of Paracetamol prescribing: The Medical Devices Committee and the Medications Safety Group have worked closely to address these issues and the process for prescribing Paracetamol has been thoroughly reviewed: As a result the Trust has now has revised its practice and this improvement will ensure that where patients are prescribed Paracetamol there will be regular monitoring by the clinical team responsible for the patient:

The attached SBAR (Situation, Background, Assessment and Recommendations) slide details the seven actions taken by the and addresses the three concerns that you have raised. An SBAR is quality improvement tool which has been adopted by the Trust and is being used as a mechanism to communicate critical information to relevant staff and foster a culture of patient safety: The SBAR has been distributed to all medical staff across the organisation and to wards and services where Paracetamol is used: The message has been disseminated to staff through the PINUP (Policy, Information, role of NHSLA and Understanding Processes) Newsletter and through the Staff Bulletin issued on 30 January 2015. In addition, the Medicines Management e-learning module has been amended to reflect the improved process and ensure the message is continually circulated to clinical staff, We are confident that the Trust has taken all reasonably practicable steps to improve the system of prescribing of Paracetamol in order to address your concerns and do hope that my response has provided you with the assurance that you and the family are looking for: If you need any further information, or if can be of any further assistance please do not hesitate t0 contact me_