Dear Sir

Re: Donna Louise Bernadette Kirkland (deceased)

Thank you for your letter of 28 July 2014 enclosing the regulation 28: Report to Prevent Future Deaths in this matter.

We welcome the Coroner’s interest and concern in ensuring future deaths are prevented and that any risks to patients around alcohol-based hand sanitising gel (alcogel) are minimised.

The Trust also shares your wish to bring the potential risks of alcogel to the Secretary of State, and is grateful to have been provided with a copy of the report that you have produced. It is not our understanding that you have sent the report to the Trust because you have identified that we need to do more than has already been done to further reduce the risk associated with alcogel. However, if we have misunderstood the purpose of you naming the Trust in the report, we would be grateful for clarification, particularly if there are further steps you believe the Trust should be taking.

Alcogel is a key part of infection control measures, both at the Coventry and Warwickshire Partnership NHS Trust and nationwide in both NHS and private hospitals. An alcohol-free alternative has recently become available to NHS institutions. It does have some drawbacks compared to alcogel. Nevertheless, prior to the hearing of the inquest this summer, the Trust had investigated for itself this alternative, and had decided to replace the wall-mounted alcogel dispensers on its premises with this alcohol-free alternative.

At the inquest the questions of access to, and use of, alcogel were explored with a number of witnesses from the Trust. Evidence was heard at the inquest, and accepted by the Coroner, that following Donna’s death the Trust had taken steps proactively to review the access to and use of alcogel across inpatient units and to raise the awareness of its staff of

in partnership with:

- Chair
– Chief Executive

Coventry & Warwickshire Partnership NHS Trust Wayside House, Wilsons Lane, Coventry, CV6 6NY Tel: 024 7636 2100 Fax: 024 7636 8949

the potential risks associated with the ingestion of alcohol. The Coroner was informed that the Trust was already in the process of replacing wall-mounted alcogel dispenser with the alcohol-free alternative. This process has now been completed.

The inquest did not identify any further steps which Coventry and Warwickshire Partnership NHS Trust might take to reduce the risk of future deaths.

The Trust will continue to monitor access to and use of alcogel across its sites.

The Trust endorses the Coroner’s wider concerns and would be happy to speak to the Department of Health if they would like more information on the lessons learned and the changes that have been made within the Trust.

From Dr Dan Poulter MP Parliamentary Under Secretary of State for Health Department Richmond House of Health 79 Whitehall London SWIA 2NS POC5 879159 Tel: 020 7210 4850 Mr Jason Pegg HM Assistant Coroner for Coventry and Warwickshire 2 2 SEP '2014 The Coroner's Office Central Police Station Little Park Street Coventry CV1 2JX Dea$ n Thank you for your letter to Jeremy Hunt about the death of Donna Kirkland. am responding on his behalf as the Minister with responsibility for patient safety. Ms Kirkland was found dead in her bed having drunk an alcohol based sanitising gel: A Lucozade bottle containing 250ml of alcohol based hand sanitising gel was found beside her bed: It was determined there was a reaction between the gel and drug Ms Kirkland had been prescribed for her condition (venlafaxine): However the level of alcohol in Ms Kirkland's blood was very high and this too would have been a risk to health even had she not been on that particular medication: Your report explains the circumstances around Ms Kirkland's death and concludes that the medical cause of death 'ingestion of alcohol and venlafaxine' _ You had a number of concerns about this case, including the following, Patients having unlimited access to alcohol based hand sanitising Patents being permitted to decant alcohol based hand sanitising gels into cups and other containers Patents being permitted to permitted to keep cups and containers of alcohol based hand sanitising gels in their rooms Lack of awareness amongst staff of the alcohol content of alcohol based hand sanitising gels and potential for such gels to be ingested. was concerned to learn that at the time of Ms Kirkland's death the Caludon Centre allowed patients to collect and store an alcohol-based solution of this kind, with the obvious potential for abuse. know that the Care Quality Commission has inspected the Caludon Centre twice this year and has required immediate improvements. (etd? gels the

National guidance is already in place in 'Preventing Suicide- A Toolkit for Mental Health Services' which can be found at http llwwnrls npsa nhs uklresources/?entryid45-85297&9-0%c2%acsuicide%c2%ac In addition, individual and environmental risk assessments should always be completed, evaluating whether the risk associated with hand-sanitizer gel is being managed in particular relation to each person's presenting profile of need: There is further national guidance detailed in 'Preventing Suicide in England- a cross- government outcomes strategy to saves lives, (Sept 2012). This strategy helps identify high risk groups such as those with both alcohol related and mental health issues_ The strategy document can be found at https IJwWWgov uklgovernmentluploadslsystem/uploadslattachment_datalfile/216928/Prev enting-Suicide-in-England-A-cross-government-outcomes-strategy-to-save-lives pdf and is also attached for your convenience would expect that the local Post Suicide Review would examine documented local measures of assessing and managing these additional risks and what learning can be gleaned to respond and manage such incidents in the future. In reviewing medication safety incidents from the NRLS, there have been relatively few incidents of ingestion of this sort: These types of incidents may however be reported to the NRLS under headings other than 'medication incidents' and further work would need to be done to identify these. Although incidents of this nature have been reported nationally, the number has significantly reduced as a result of local risk mitigation measures as described in the guidance above. However; there will of course be continued national oversight of reports and learning from such incidents_ hope that this information is helpful and thank you for bringing the circumstances of Ms Kirkland's death to our attention: (t hib DR DAN POULTER